ESOPHAGEAL INTRAMURAL DISSECTION WITH PNEUMOMEDIASTINUM SECONDARY TO FOREIGN BODY INGESTION

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Esophageal injuries are associated with significant morbidity and mortality. Intramural esophageal dissection (IED) is a rare entity involving separation of the mucosal and muscular layers of the esophagus creating a true and false lumen (1). We present a patient with esophageal dissection secondary to foreign body ingestion. CASE PRESENTATION: A 38-year-old freedom impaired man with schizophrenia presented with severe odynophagia after a suicide attempt by ingestion of plastic bags and a spoon. He vomited multiple times afterwards and was intubated due to respiratory distress. He was afebrile and hemodynamically stable. Physical exam was significant for crepitus around the neck and shoulders with severe pain to palpation. Abnormal labs included mild leukocytosis and elevated BUN, Cr, and CK. The esophagram revealed subcutaneous and mediastinal emphysema with no extravasation of contrast. Cervical and thoracic computed tomography (CT) with barium revealed neck and upper chest soft tissue emphysema involving the retropharyngeal space along with pneumomediastinum and pneumopericardium (Figure 1 & 2). ENT performed a microdirect laryngoscopy and rigid bronchoscopy removing a foreign body from the left hypopharynx. Given the risk for mediastinitis, intravenous antibiotics were started. Two days later, ENT repeated direct laryngoscopy and found an esophageal dissection extending from the level of C2 to T2 with separation of the posterior pharyngeal wall from the deep vertebral space (Figure 3). The patient was kept intubated to allow time for healing along with moderate sedation to prevent coughing from disrupting the epithelialization. Repeat CT of the head and neck showed minimal emphysema, esophageal and prevertebral soft tissue thickening, pleural effusions, and pneumonia. The patient was successfully extubated. Repeat esophagram noted contrast in the right and left mainstem bronchi. Given aspiration risk, an open gastrostomy tube was placed for enteral nutrition. DISCUSSION: IED is commonly due to iatrogenic interventions, but can occur rarely secondary to foreign body ingestion. Other causes include a sudden increase in intra-esophageal pressure or submucosal bleeding (1). Diagnosis is confirmed by esophagram, CT scan or standard endoscopy. IED may present with pneumomediastinum, which is hypothesized to be secondary to gas diffusion across the esophageal muscular layers (2). Management is typically conservative. CONCLUSIONS: Foreign bodies are a rare cause of IED. Early investigation and maintaining a strong suspicion for esophageal perforation are key to ensuring a favorable outcome. Reference #1: Soulellis CA, Hilzenrat N, Levental M. Intramucosal esophageal dissection leading to esophageal perforation: case report and review of the literature. Gastroenterol Hepatol (NY). 2008;4(5):362-365. http://www.ncbi.nlm.nih.gov/pubmed/21904510. Reference #2: Lee CH, Chen WP, Feng YM, Huang PY. Iatrogenic Full-Length Intramural Esophageal Dissection Associated with Pneumomediastinum after Attempted Diagnostic Gastroscopy. Journal of Clinical Case Reports. 2014; 4:443. DISCLOSURES: No relevant relationships by naseem helo, source=Web Response My spouse/partner as a Speaker/Speaker's relationship with Salix Please note: $1001 - $5000 Added 03/13/2019 by Ebtesam Islam, source=Web Response, value=Speaker fee No relevant relationships by Sarah Jaroudi, source=Web Response No relevant relationships by Barbara Mantilla, source=Web Response No relevant relationships by Kenneth Nugent, source=Web Response