Esophageal Perforation after Placement of Wireless Bravo pH Probe

Abstract

Purpose: Esophageal pH monitoring is important in patients with atypical or refractory gastroesophageal reflux disease (GERD). The technology of esophageal acid exposure monitoring with the use of a catheter-free radiotelemetric pH capsule, called the BRAVO™ pH monitoring system (Medtronic Inc., Shoreview, MN) is a recent new technique demonstrated to be comparable to the conventional catheter system for quantifying esophageal pH. Its use is more comfortable and allows the patient to be more active during the test period with minimal complications. We describe a case of esophageal perforation during that occurred during the placement of the catheter delivery system. A 67/F with recurrent reflux underwent EGD and placement of a BRAVO™ pH probe. EGD was normal. During advancement of the BRAVO™ catheter probe, resistance was met at the proximal esophagus. Immediate withdrawal of the catheter and endoscopy revealed a large mucosal tear and the procedure was immediately aborted. After the procedure, the patient had chest discomfort, was afebrile and hemodynamically stable. Cardiac, pulmonary and abdominal examinations were normal. CBC and electrolytes are all normal other than mild leukocytosis (WBC 13.6) which normalized the next day. Pharyngoesophagram with gastrograffin contrast demonstrated extraluminal extravasation of gastrograffin in the upper esophagus along the anterior left aspect. The CT scan of the chest demonstrated air in the posterior mediastinum consistent with esophageal perforation. The patient was admitted for observation and managed conservatively, i.e. NPO, pain control, IV hydration, and coverage with broad spectrum antibiotics. The patient remained stable over the next few days, and a clear liquid diet was started on the 4th hospital day was eventually discharged on the 6th hospital day without developing further complications, with the advice of advancing to a regular diet after within one week, and to continue a one-week course of oral antibiotics. After several weeks after the incident, the patient was eventually able to resume her normal diet and activities without developing further complications. The BRAVO™ pH system is well tolerated and its use in several institutions is becoming more widespread. Recognition that esophageal perforation may be a complication is important. The physician should consider such risks in the consideration of determining the appropriateness of testing in patients with GERD.