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ESOPHAGEAL TEAR ASSOCIATED WITH COMBINED EOSINOPHILIC/PEPTIC ESOPHAGITIS IN A SIXTEEN-YEAR-OLD FOLLOWING MINOR BLUNT TRAUMA

J Dassa, E Drouin
Division of Gastroenterology and Nutrition, Department of Pediatrics, Hôpital Sainte-Justine, Montreal, Quebec

BACKGROUND: Rupture of the intrathoracic esophagus secondary to blunt trauma is very rare, and is reported only with severe trauma in children. Underlying esophageal pathology is a risk factor for esophageal perforation. Gastroesophageal reflux disease (GERD) has been reported in few cases of esophageal rupture in both adults and children. While two adult cases have been associated with eosinophilic esophagitis (EE), no such cases have yet been reported in children.
CASE PRESENTATION: A 16-year-old male known for atopic disease and longstanding solid food dysphagia presented to an adult hospital with chest pain following a minor snowboarding fall. Initial chest x-ray and computed tomography (CT) scan were interpreted as normal. He was discharged with a diagnosis of chest contusion but returned 12 days later for worsening dysphagia and odynophagia. Upper endoscopy revealed a thoracic esophageal large mucosal defect. Chest CT and esophagogram study showed a thoracic esophageal tear and large intramural dissection. The patient recovered completely after 40 days of conservative treatment including bowel rest, total parenteral nutrition and intravenous antibiotics. The patient was seen at our center one year later for occasional dysphagia and heartburn. Physical examination was unremarkable and complete blood count was within normal limits. Upper endoscopy revealed tear scar tissue and furrow lines in the upper two thirds of the esophagus as well as linear erosions in the distal esophagus. Esophageal biopsy showed eosinophilic infiltration (15 eosinophils per high-power field), mild basal layer hyperplasia and papillary lengthening. Skin prick test and RAST levels were positive for soy, wheat, rice, corn and nuts. The patient was placed on an exclusion diet with which he was not compliant, as well as esomeprazole therapy which he took as prescribed. At six months follow-up, his reflux symptoms are greatly improved but he remains with dysphagia.
DISCUSSION: To our knowledge, this is the first described pediatric case of esophageal tear and dissection associated with EE, extending the risk profile of this pathology in the pediatric population. The esophageal injury with minor blunt trauma seen in this patient may be explained by his underlying EE and GERD pathology and illustrates the importance of looking for underlying esophageal pathology in such cases. Physicians and their patients should therefore be sensitized to the fragility of the esophagus in EE and GERD.

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