Conservative management for an esophageal perforation in a patient presented with delayed diagnosis: a case report review of the literature

Abstract

Esophageal perforation is a serious condition with a high mortality rate. Successful therapy depends on the size of the rupture; the time elapsed between rupture and diagnosis, and the underlying health of the patient. Common causes of esophageal perforation include medical instrumentation, foreign-body ingestion, and trauma. A case of esophageal perforation due to fish bone ingestion in a 67-year-old male is described here, with a review of the pertinent literature. The patient presented with chest pain, fever and right-sided pleural effusion. Initial evaluation was nondiagnostic. The water-soluble contrast swallow test showed no evidence of leakage. Computed tomography scan demonstrated a pneumomediastinum, and right-sided hydropneumothorax. The patient was successfully treated using conservative measures.

Figure 1.

Chest X-ray demonstrated right pleural effusion, but no radio-opacity was detected and there was no evidence of pneumomediastinum or subcutaneous emphysema.

Figure 2.

A hypaque swallow study failed to demonstrate extravasation of contrast medium.

Figure 3.

Erect chest X-ray a few hours later demonstrated contrast medium extravasation accompanied with large pleural effusion.

Figure 4.

Subsequent CT scan demonstrated right sided pneumothorax, extended right sided pleural effusion and a small amount of air in the mediastinum.

Figure 5.

A confirmative esophagogastroduodenoscopy revealed a small distal esophageal perforation.

Figure 6.

A covered self-expanding metallic stent was inserted endoscopically, across the tear site to prevent ongoing local infection.

Figure 7.

Follow up CT scan at 3 months.