A Case of Esophageal Perforation Presenting as Cavitary Pneumonia: Diagnostic and Therapeutic Challenges

Esophageal perforation, a rare condition, can arise from iatrogenic, traumatic, or spontaneous origins. Even when therapy is initiated within the first 24 hours, it is associated with a mortality rate of up to 25%. Due to the varied initial presentation, treatment may be delayed, leading to poorer outcomes. Here, we present a unique case of a 27-year-old schizophrenic patient who initially presented with acute respiratory failure and septic shock and was ultimately diagnosed with cavitary pneumonia secondary to esophageal perforation.

Bedside ultrasound-guided water injection assists endoscopically treatment in esophageal perforation caused by foreign bodies: A case report

BACKGROUND Fishbone migration from the esophagus to the neck is relatively uncommon in clinical practice.Several complications secondary to esophageal perforation after ingestion of a fishbone have been described in the literature.Typically,a fishbone is detected and diagnosed by imaging examination and is usually removed by a neck incision.CASE SUMMARY Herein,we report a case of a 76-year-old patient with a fishbone in the neck that had migrated from the esophagus and that was in close proximity to the common carotid artery,and the patient experienced dysphagia.An endoscopically-guided neck incision was made over the insertion point in the esophagus,but the surgery failed due to having a blurred image at the insertion site during the operation.After injection of normal saline laterally to the fishbone in the neck under ultrasound guidance,the purulent fluid outflowed to the piriform recess along the sinus tract.With endoscopic guidance,the position of the fish bone was precisely located along the direction of liquid outflow,the sinus tract was separated,and the fish bone was removed.To the best of our knowledge,this is the first case report describing bedside ultrasound-guided water injection positioning combined with endoscopy in the treatment of a cervical esophageal perforation with an abscess.CONCLUSION In conclusion,the fishbone could be located by the water injection method under the guidance of ultrasound and could be accurately located along the outflow direction of the purulent fluid of the sinus by the endoscope and was removed by incising the sinus.This method can be a nonoperative treatment option for foreign body-induced esophageal perforation.

Delayed presentation of intrathoracic esophageal perforation after pneumatic dilation for achalasia

Pneumatic dilation(PD)is considered to be a safe and effective first line therapy for achalasia.The major adverse event caused by PD is esophageal perforation but an immediate gastrografin test may not always detect a perforation.It has been reported that delayed management of perforation for more than 24 h is associated with high mortality.Surgery is the treatment of choice within 24 h,but the management of delayed perforation remains controversial.Hereby,we report a delayed presentation of intrathoracic esophageal perforation following PD in a 48-year-old woman who suffered from achalasia.She completely recovered after intensive medical care.A review of the literature is also discussed.

predictors for failure of stent treatment for benign esophageal perforations- a single center 10-year experience

AIM: To investigate possible predictors for failed self-expandable metallic stent (SEMS) therapy in consecutive patients with benign esophageal perforation-rupture (EPR).

Esophageal perforation caused by fish vertebra ingestion in a seven-month-old infant demanded surgical intervention: A case report

A seven-month-old infant was admitted to our hospital with a 1-wk history of shortness of breath, dysphagia, and fever. Diagnosis of esophageal perforation follow- ing fish vertebra ingestion was made by history review, pneumomediastinum and an irregular hyperdense lesion noted in initial chest radiogram. Neck computed tomo- graphy (CT) confirmed that the foreign body located at the cricopharyngeal level and a small esophageal tra- cheal fistula was shown by esophagogram. The initial re- sponse to treatment of fish bone removal guided by pan- endoscopy and antibiotics administration was poor since pneumothorax plus empyema developed. Fortunately, the patient’s condition finally improved after decortica- tion, mediastinotomy and perforated esophagus repair. To our knowledge, this is the first case report of esopha- geal perforation due to fish bone ingestion in infancy. In addition to particular caution that has to be taken when feeding the innocent, young victim, it may indicate the importance of surgical intervention for complicated esophageal perforation in infancy.

Vertebral body infection due to esophageal perforation caused by ingestion of fishbone:a case report

Background:Esophageal injury is a common complication of foreign bodies in the upper gastrointestinal tract,but bilateral pleural effusion or vertebral infection is a rare condition due to a swallowed fishbone.It is considerably difficult for a physician to diagnose quickly because of incomplete patient history of foreign bodies ingestion and/or insufficient experiences.Patient concerns:We describe the case of a 56-year-old man who was admitted to an emergency medical department owing to a low to moderate fever for 7 days.After a series of examinations,the patient was diagnosed with esophageal perforation(EP)caused by a fishbone that was swallowed half a month ago.Diagnoses:About 12 days after the onset of fever,he was diagnosed with EP based on the gastric endoscopic images combined with histological section and sufficient history of the disease.About 2 months later,the patient has obvious back pain and lack of strength in two legs and was diagnosed with vertebral body infection.Interventions:Antibiotic therapy,multi-disciplinary team(MDT),and surgical intervention had been exerted.Outcomes:It is very fortunate for this patient to have a good prognosis due to a timely diagnosis and proper management.Muscle power has attained level 5.Lessons:Several lessons can be learned from this case;for example,physicians should be alerted to the EP,endoscopic intervention should be prompt,antibiotics should be used regularly,and so on.

Routine nasogastric tube placement in patients with small esophageal perforation after endoscopic foreign body removal may be unnecessary:a propensity score matching analysis

Background:Nasogastric tube(NGT)placement is part of the post-operative management of upper gastrointestinal perforation,but its routine use in esophageal perforation(EP)caused by foreign bodies remains unclear.The purpose of this research was to investigate the necessity for routine NGT placement in patients with EP after endoscopic foreign body removal.Methods:A total of 323 patients diagnosed with EP caused by foreign bodies at the First Affiliated Hospital of Nanchang University between January 2012 and December 2021 were included in this retrospective study.Patients were divided into the NGT group and the non-NGT group according to whether or not NGT placement was performed.The perforation healing rate,post-operative adverse events,hospital stay,and death rate were analysed using a 1:1 propensity score matching model.Results:Before matching,there were 263 patients in the NGT group and 60 patients in the non-NGT group.There were significant differences in the time to treatment,infection,albumin,and types of endoscopy between the two groups,while the length of hospital stay in the NGT group was significantly longer than that in the non-NGT group.After 1:1 propensity score matching,48 pairs of patients were matched between the two groups.The perforation healing rate,post-operative adverse events,length of hospital stay,and death rate did not show significant differences between the two groups.Conclusions:For patients with small EP caused by foreign bodies,routine NGT placement after endoscopic foreign body removal may be unnecessary.

How to preserve the native or reconstructed esophagus after perforations or postoperative leaks: A multidisciplinary 15-year experience

BACKGROUND Esophageal perforation or postoperative leak after esophageal surgery remain a life-threatening condition.The optimal management strategy is still unclear.AIM To determine clinical outcomes and complications of our 15-year experience in the multidisciplinary management of esophageal perforations and anastomotic leaks.METHODS A retrospective single-center observational study was performed on 60 patients admitted at our department for esophageal perforations or treated for an anastomotic leak developed after esophageal surgery from January 2008 to December 2023.Clinical outcomes were analyzed,and complications were evaluated to investigate the efficacy and safety of our multidisciplinary management based on the preservation of the native or reconstructed esophagus,when feasible.RESULTS Among the whole series of 60 patients,an urgent surgery was required in 8 cases due to a septic state.Fifty-six patients were managed by endoscopic or hybrid treatments,obtaining the resolution of the esophageal leak/perforation without removal of the native or reconstructed esophagus.The mean time to resolution was 54.95±52.64 days,with a median of 35.5 days.No severe complications were recorded.Ten patients out of 56(17.9%)developed pneumonia that was treated by specific antibiotic therapy,and in 6 cases(10.7%)an atrial fibrillation was recorded.Seven patients(12.5%)developed a stricture within 12 months,requiring one or two endoscopic pneumatic dilations to solve the problem.Mortality was 1.7%.CONCLUSION A proper multidisciplinary approach with the choice of the most appropriate treatment can be the key for success in managing esophageal leaks or perforations and preserving the esophagus.

A rare case of circumferential intramural dissection of thoracic esophagus with contained esophageal perforation

In this report, a full account of an extremely rare case on esophageal intramural dissection （EID） is presented. A 56-year-old female patient, misdiagnosed as esophageal mediastinal fistula under endoscopic view, was diagnosed correctly as EID with contained esophageal perforation in the operation and cured by thoracic esophagectomy.

Surgical Treatment of Perforation with Esophageal Carcinoma

OBJECTIVE To determine the ideal method of surgical preoperative treatment for perforation with esophageal carcinoma.METHODS 36 cases of perforation with esophageal carcinoma were treated surgically in this series.Perforations occurred into the right lung in 14 cases.the mediastinum in 17 cases and treachea in 5 cases.Open thoracic surgery was performed in 34 cases.in which the right thoracic approach using a 3-incision method was applied in 16 cases,and operation by stages in 15 cases.Of the 34 cases.retrosternal substitution of the esophagus with stomach or colon was performed in 26 cases.RESULTS Surgery was successful in 31 cases and operative death occurred in 3 cases.The postoperative follow up study was from 3-72 months.Of these cases 15 were alive 15 7-12 months,2 at 24 months.and 1 at 72 months.The results can be considered satisfactory.CONCLUSION The therapeutic results of surgical treatment of perforation with esophageeal carcinoma were markedly superior to that of conventional conservative treatment.The authors suggest that surgical interventionwithout delay should be undertaken for patients having a perforation with carcinoma of the esophagus.A right thoracic approach with a 3-incision method（retrosternal replacement of esophagus with stomach or colon0or operation by stages is preferable.

Severe esophageal injury after radiofrequency ablation-a deadly complication

Various degrees of esophageal injury have been described after radiofrequency ablation performed for treatment of atrial fibrillation. The main mechanism of injury is thermal and may lead to a range of esophageal mucosal changes, some clinically insignificant, however when deep ulceration occurs, this may be further complicated by perforation and mediastinitis, a rare but life threatening sequelae. We present a case of a severe esophageal injury leading to mediastinitis, with interesting endoscopic findings.

Endoscopic extraction of a submucosal esophageal foreign body piercing into the thoracic aorta:A case report

BACKGROUND Aorto-esophageal injury is a rare but life-threatening complication of esophageal foreign bodies,which typically requires open surgery.The best way to treat patients with this condition remains unclear.To date,few reports have described an aortic wall directly penetrated by a sharp foreign body.Here,we present a rare case of a fishbone completely embedded in the esophageal muscularis propria and directly piercing the aorta,which was successfully treated by endoscopy and thoracic endovascular aortic repair(TEVAR).CASE SUMMARY We report the case of a 71-year-old man with a 1-d history of retrosternal pain after eating fish.No abnormal findings were observed by the emergency esophagoscopy.Computed tomography showed a fishbone that had completely pierced through the esophageal mucosa and into the aorta.The patient refused to undergo surgery for personal reasons and was discharged.Five days after the onset of illness,he was readmitted to our hospital.Endoscopy examination showed a nodule with a smooth surface in the middle of the esophagus.Endoscopic ultrasonography confirmed a fishbone under the nodule.After performing TEVAR,we incised the esophageal mucosa under an endoscope and successfully removed the fishbone.The patient has remained in good condition for 1 year.CONCLUSION Incising the esophageal wall under endoscope and extracting a foreign body after TEVAR may be a feasible option for cases such as ours.

Palliative cardia resection with gastroesophageal reconstruction for perforated carcinoma of the gastroesophageal junction

Iatrogenic perforation of esophageal cancer or cancer of the gastroesophageal(GE)junction is a serious complication that,in addition to short term morbidity and mortality,significantly compromises the success of any subsequent oncological therapy.Here,we present an 82-year-old man with iatrogenic perforation of adenocarcinoma of the GE junction.Immediate surgical intervention included palliative resection and GE reconstruction.In the case of iatrogenic tumor perforation, the primary goal should be adequate palliative(and not oncological)therapy.The different approaches for iatrogenic perforation,i.e.surgical versus endoscopic therapy are discussed.

False esophageal hiatus hernia caused by a foreign body: A fatal event

Foreign body ingestion is a common complaint in gastrointestinal clinics. It is usually not difficult to diagnose because most of the patients report a definitive history of accidental foreign body ingestion. However, in rare cases, patients do not have a clear history. Thus, the actual condition of the patient is difficult to diagnosis or is misdiagnosed; consequently, treatment is delayed or the wrong treatment is administered, respectively. This report describes a fatal case of esophageal perforation caused by an unknowingly ingested fishbone, which resulted in lower esophageal necrosis, chest cavity infection, posterior mediastinum fester, and significant upper gastrointestinal accumulation of blood. However, his clinical symptoms and imaging data are very similar with esophageal hiatal hernia. Unfortunately, because the patient was too late in consulting a physician, he finally died of chest infection and hemorrhage caused by thoracic aortic rupture. First, this case report underlines the importance of immediate consultation with a physician as soon as symptoms are experienced so as not to delay diagnosis and treatment, and thus avoid a fatal outcome. Second, diagnostic imaging should be performed in the early stage, without interference by clinical judgment. Third, when computed tomography reveals esophageal hiatus hernia with stomach incarceration, posterior mediastinal hematoma, and pneumatosis caused by esophageal, a foreign body should be suspected. Finally, medical professionals are responsible for making people aware of the danger of foreign body ingestion, especially among children, those who abuse alcohol, and those who wear dentures, particularly among the elderly, whose discriminability of foreign bodies is decreased, to avoid dire consequences.

Secondary aortoesophageal fistula initially presented with empyema after thoracic aortic stent grafting:A case report

BACKGROUND Massive upper gastrointestinal(GI)bleeding is usually urgent and severe,and is mostly caused by GI diseases.Aortoesophageal fistula(AEF)after thoracic aortic stent grafting is a rare cause of this condition,and has a poor prognosis with a high mortality rate.The clinical symptoms of AEF are usually nonspecific,and the diagnosis is often difficult,especially when upper GI bleeding is absent.Early identification,early diagnosis,and early treatment are very important for improving prognosis.CASE SUMMARY A 74-year-old man was admitted to the infectious disease department with>10-d fever and 10-mo prior history of thoracic aortic stent grafting for thoracic aortic penetrating ulcers.Blood tests revealed elevated inflammatory indicators and anemia.Chest computed tomography(CT)showed postoperative changes of the aorta after endovascular stent graft implantation,pulmonary infection and pleural effusion.Pleural effusion tests showed empyema.After 1 wk of anti-infective treatment,temperature returned to normal and chest CT indicated improvement in pulmonary infection and reduction of pleural effusion.Esophageal endoscopy was performed because of epigastric discomfort,and showed a large ulcer with blood clot in the middle esophagus.However,on day 11,hematemesis and melena developed suddenly.Bleeding stopped temporarily after hemostatic treatment and bedside endoscopic hemostasis.Thoracic and abdominal aortic CT angiography confirmed AEF.Later that day,he suffered massive hemorrhage and hemorrhagic shock.Eventually,his family elected to discontinue treatment.CONCLUSION AEF should be strongly considered in patients with a history of aortic intervention who present with fever,especially with empyema.

ESOPHAGUS-STOMACH-ABDOMINAL WALL DRAINAGE FOR DELAYED INTRATHORACIC ESOHPAGEAL PERFORATION

Objective To design a technique of esophagus-stomach-abdominal wall drainage for the de-layed intrathoracic esophageal perforation and to improve the therapeutic results. Methods Four patients were treated by this simplified technique. There were 1 case of lower intrathoracic esophageal perforation to the left thorax , 1 high and 2 middle perforation to the right. This technique used two plastic tubes (chest tube) in a diameter about 1 .2cm . One tube served as an intercostal drainage tube to drain purulent effusion , the other was inserted abdominally through stomach to the esophagus about 10cm above the esophageal perforation. Results The four patients were treated successfully by the esophagus-stomach-abdominal wall drainage. There was no mortality or severe morbidity or complication. Hospitalizations were shortened. Conclusion This technique is simple, safe and effective. It may provide a more promising alternative method of treatment for delayed esophageal perforation, especially in the critically ill patients. The procedure can also be extended to deal with esophagus-stomach anastomotic leak.

食管异物穿孔并发酮症酸中毒1例

1临床资料患者,女,44岁,因“误咽鸭骨后咽痛、吞咽困难2 d”于2022-11-14入院。患者自诉2 d前不慎咽入大块鸭骨,当时即感咽痛,强行咽入大块食物后无缓解。随后感觉气喘、吞咽困难,喉结下方右侧疼痛明显。既往史:近偶有2年血糖偏高,未规范诊治。查体:右侧颈部见一大小约1.5 cm x1.0 cm隆起,触痛明显,咽黏膜稍充血,双侧扁桃体无充血、肿大。

Current approach for Boerhaaves syndrome:A systematic review of case reports

There is no consensus on the appropriate therapeutic strategy for Boerhaave syndrome due to its rarity and changing therapeutic approaches.We conducted a systematic review of case reports documenting Boerhaave syndrome.AIM To assess the therapeutic methods and clinical outcomes and discuss the current trends in the management of Boerhaave syndrome.METHODS We searched PubMed,Google scholar,MEDLINE,and The Cochrane Library for studies concerning Boerhaave syndrome published between 2017 and 2022.RESULTS Of the included studies,49 were case reports,including a total of 56 cases.The mean age was 55.8±16 years old.Initial conservative treatment was performed in 25 cases,while operation was performed in 31 cases.The rate of conservative treatment was significantly higher than that of operation in cases of shock vital on admission(9.7%vs 44.0%;P=0.005).Seventeen out of 25 conservative cases(68.0%)were initially treated endoscopic esophageal stenting;2 of those 17 cases subsequently underwent operation due to poor infection control.Twelve cases developed postoperative leakage(38.7%),and 4 of those 12 cases underwent endoscopic esophageal stenting to stop the leakage.The length of the hospital stay was not significantly different between the conservative treatment and operation cases(operation vs conservation:33.52±22.69 vs 38.81±35.28 days;P=0.553).CONCLUSION In the treatment of Boerhaave syndrome,it is most important to diagnose the issue immediately.Primary repair with reinforcement is the gold-standard procedure.The indication of endoscopic esophageal stenting or endoluminal vacuum-assisted therapy should always be considered for patients in a poor general condition and who continue to have leakage after repair.

Managing esophagocutaneous fistula after secondary gastric pullup:A case report

BACKGROUND Gastric pull-up(GPU)procedures may be complicated by leaks,fistulas,or stenoses.These complications are usually managed by endoscopy,but in extreme cases multidisciplinary management including reoperation may be necessary.Here,we report a combined endoscopic and surgical approach to manage a failed secondary GPU procedure.CASE SUMMARY A 70-year-old male with treatment-refractory cervical esophagocutaneous fistula with stenotic remnant esophagus after secondary GPU was transferred to our tertiary hospital.Local and systemic infection originating from the infected fistula was resolved by endoscopy.Hence,elective esophageal reconstruction with freejejunal interposition was performed with no subsequent adverse events.CONCLUSION A multidisciplinary approach involving interventional endoscopists and surgeons successfully managed severe complications arising from a cervical esophagocutaneous fistula after GPU.Endoscopic treatment may have lowered the perioperative risk to promote primary wound healing after free-jejunal graft interposition.

Neck and mediastinal hematoma caused by a foreign body in the esophagus with diagnostic difficulties:A case report

BACKGROUND Esophageal foreign body(FB)is a common clinical emergency.Clinically,computed tomography(CT)scans are important in the diagnosis of FBs in the esophagus.Here,we report a case of esophageal perforation and cervical hematoma,caused by a FB,whose uniqueness made rapid diagnosis difficult.CASE SUMMARY A 42-year-old man was transferred to our hospital with esophageal perforation,which was accompanied by cervical and mediastinal hematoma.CT scans only revealed a black shadow,approximately 2.5 cm in diameter,in the upper esophagus.After multidisciplinary discussion,he was quickly subjected to mediastinal hematoma resection,peripheral nerve compression release,esophageal FB removal and esophagectomy.Eventually,we removed a small crab with a pointed tip from his esophagus.CONCLUSION This was an unusual case of occurrence of sharp polygonal esophageal FBs caused by a small crab.Rapid diagnosis of this FB was difficult,mainly due to its translucent nature.Occurrence of sharp FBs,with cavities that sometimes only appear as black shadows on CT scans,can easily be mistaken for esophageal lumens.More attention should be paid to such sharp polygonal FBs.