Acute Crit Care.  2021 Aug;36(3):264-268. 10.4266/acc.2020.01067.

Circumferential esophageal perforation resulting in tension hydropneumothorax in a patient with septic shock

• Saffo S
• Farrell J
• Nagar A

• KMID: 2519455
• DOI: http://doi.org/10.4266/acc.2020.01067

Abstract

Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.

Keyword

esophageal perforation; hydropneumothorax; septic shock

Figure

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  Figure 1. Plain films of the chest on presentation (A) and after (B) endotracheal intubation revealing development of bilateral hydropneumothorax and pneumomediastinum (black arrow). After chest tube placement, dark fluid was evacuated (C).

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  Figure 2. Computed tomography (A) revealing air tracking from the esophagus to the pleural spaces (solid white arrows) and endoscopy (B) revealing separation of the necrotic esophagus (solid black arrow) from viable stomach (dashed black arrow) with a nasogastric tube (arrowhead) going through the perforation into the mediastinum. An unsutured fully-covered metal stent was deployed across the perforation (C).

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