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RECURRENT MICROPERFORATION CAUSING PNEUMOMEDIASTINUM IN A PATIENT WITH EOSINOPHILIC ESOPHAGITIS
C Struthers, M CurleyDalhousie University, Halifax, NS
Aims: Esophageal perforation in patients with eosiniphilic esophagitis has been reported with food impaction, dilatation as well as simple passage of the endoscope. Perforation in the absence of significant mechanical trauma has rarely been described.
Methods: We describe a case of recurrent pneumomediastinum secondary to spontaneous esophageal microperforation in a young man who was eventually diagnosed with eosinophilic esophagitis.
Results: A 20-year-old man with one-year history of intermittent dysphagia presented to hospital with acute onset of retrosternal chest pain associated with nausea, vomiting and diarrhea. He was sent home on oral antiemetics.
Four days later, he returned with ongoing persistent dysphagia. A CT scan showed extensive subcutaneous emphysema, pneumomediastinum and a small right pneumothorax, but no extravasation of oral contrast. He was admitted to hospital with a diagnosis of esophageal microperforation. After six days of conservative management with intravenous fluids and antiemetics he was discharged home on a soft diet. One-month follow-up chest radiograph was normal.
He returned two months later with identical symptoms. A chest radiograph showed subcutaneous emphysema and a possible tiny pneumomediastinum. A gastrograffin swallow could not identify esophageal perforation. He was discharged home after three days.
Gastroscopy, performed two months later, showed LA Class B esophagitis at the gastroesophageal junction, but was otherwise normal. Oral proton pump inhibitor was started.
Repeat gastroscopy, two months later, showed persistent esophagitis and the remainder of the esophagus had a diffusely granular appearance with spots of white exudate. Biopsies showed active esophagitis with marked eosinophilic infiltrate, consistent with eosinophilic esophagitis. Swallowed fluticasone was added and at one-year follow-up, there has been complete resolution of dysphagia with no further perforations.
Conclusions: It is well established that patients with eosinophilic esophagitis are at risk of perforation during endoscopy, especially if dilatation or removal of food bolus are attempted. This rare case presents a patient with two radiographically-documented spontaneous microperforations.
A history of dysphagia in a young person should prompt early gastroscopy. Morphologic features of eosinophilic esophagitis are not always present which underscores the importance of empiric biopsies throughout the esophagus. Had the diagnosis of eosinophilic esophagitis been confirmed earlier, the second perforation may have been avoided.