(1162) Atypical Presentation of Esophageal Perforation With Bilateral Pleural Effusions

Introduction: Esophageal perforation is a rare and life threatening condition with morbidity and mortality reaching up to 20% of cases.1 80% of cases are secondary to endoscopic instrumentation, whilst the reminder of causes are due to spontaneous rupture, severe retching or vomiting.2 The high mortality arises from delayed diagnosis, contamination of pleura and mediastinum especially witnessed with spontaneous rupture. Definitive management of this include stent placement, graft and repair.

Description: 41-year-old male with a history of hypertension and intravenous drug use who
presented after being found altered and unable to provide any significant history. He was found
to be hypoxic and agitated requiring ketamine and versed for sedation and was eventually
intubated due to respiratory distress. CT chest showed bilateral large pleural effusions. Chest
tubes were inserted with drainage of large amounts of brownish fluid with cultures growing
mixed organisms suspicious for oropharyngeal source. Repeat CT chest revealed mild pneumomediastinum. Gastrografin study showed an esophageal perforation with leak into the left pleural cavity. He underwent primary repair with intercostal flap and covered esophageal stent. He had a complicated course afterwards with developing esophageal abscess with persistent leakage and underwent Endovac. EGD following this showed a healing fistula site.

Discussion: Esophageal perforation is a rare and emergent condition with high mortality rates depending on the timing of diagnosis and intervention. In 70% of cases, patients present with sudden acute chest pain with associated symptoms including neck pain, dysphonia, hematemesis, tachycardia, and fever.1 In 25% of cases, patients would have Mackler’s triad of vomiting, chest pain, and subcutaneous emphysema.3 More rarely, patients present with bilateral pleural effusions and pneumomediastinum as was the case with our patient, which is only encountered in 10% of cases.4 Early diagnosis and treatment are key given the mortality during the first 24 hours is 10-20%. This raises quickly to 50% with late diagnosis.2,5