BACKGROUND

Oesophageal perforation with mediastinitis is usually a severe condition that can quickly progress to sepsis and death. For this reason the literature recommends very aggressive therapy with surgery in most cases, or endoscopic treatment for selected patients. In our case the unusual presentation and success of a conservative approach demonstrates that small perforations can lead to a minor contamination of the mediastinum, resulting in a completely different outcome.

CASE PRESENTATION

A 53-year-old woman, with a history of depression treated for 4 years, presented to the emergency room with an intense thoracic pain; described as a “stabbing pain”, it was located in the precordium and radiated to the back, which grew worse with mobilisation, deep inspiration and swallowing. At admission, the axillary temperature was 36°C, pulse was 72 beats/min, and blood pressure was 120/70 mm Hg. The physical examination was normal.

INVESTIGATIONS

There were no alterations in the electrocardiogram (ECG) and the chest x ray was normal. Laboratory tests including blood counts, cardiac enzymes, and D-dimer were normal except for an elevated C reactive protein (CRP) concentration of 6.81 mg/dl (normal <0.5 mg/dl). The endoscopy did not find signs of perforation or abnormalities. The chest computed tomography (CT) scan revealed subtle oesophageal wall thickening and a very small amount of fluid collection with air (fig 1).

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Figure 1

Computed tomography scan showing subtle oesophageal wall thickening and small fluid collection with air.

DIFFERENTIAL DIAGNOSIS

Intense thoracic pain in the precordium radiating to the back in a middle age women demands prompt evaluation of cardiovascular diseases, namely acute coronary syndrome, aortic dissection and pulmonary embolism. The refractory pain with normal ECG and normal cardiac enzymes excluded the diagnosis of acute coronary syndromes. The likelihood of a pulmonary embolism was weakened by the normal D-dimer. The CT scan was performed to evaluate the thoracic aorta, which was normal, and it disclosed mediastinitis.

OUTCOME AND FOLLOW-UP

Even after analgesia with tramadol and ketoprofen, the intense thoracic pain persisted. After more detailed questioning, the patient revealed a history of fish bone ingestion and choking a week before. With the possibility that an oesophageal perforation had produced a blocked mediastinitis, we initiated antibiotic treatment with ciprofloxacin and clindamycin. After 2 days the patient’s thoracic pain was considerably alleviated, and laboratory tests showed a reduction in CRP to 3.15 mg/dl. After 5 days of antibiotic treatment, the CRP concentration was 0.56 mg/dl and the patient was asymptomatic. She was discharged from hospital after 8 days on medical treatment, and the antibiotic regimen was continued up to 21 days. One month after the diagnosis, the chest CT scan was repeated and showed complete resolution of the oesophageal wall thickening and related collection.

DISCUSSION

Oesophageal perforation leading to acute mediastinitis is an uncommon and aggressive disease.1 The common presenting symptoms when the oesophagus is injured are dysphagia and thoracic pain. When mediastinitis starts, signs of sepsis and worsening of pain become evident.

The possible causes of oesophageal perforation are iatrogenic, spontaneous rupture, foreign body ingestion, and trauma. The most common cause of oesophageal perforation is iatrogenic, mainly due to endoscopy procedures. Other possible causes, namely spontaneous rupture (Boerhaave syndrome), foreign body ingestion and trauma, are responsible for only 20% of perforations.2 The most common foreign bodies damaging the thoracic oesophagus include bones, especially chicken or pork bones (fish bones more commonly lodge in the hypopharynx), bits of shellfish shells, partial dentures, plastic eating utensils (frequently in the mentally disturbed), and metal objects such metal beverage can openers.

Disruption of the oesophagus in the thoracic cavity permits the egress of oropharyngeal bacteria and gastric contents into the visceral compartment of the mediastinum. Oesophageal perforation may present with vomiting, chest pain, and subcutaneous emphysema. The symptoms of acute mediastinitis include chills, high fever, tachycardia and sepsis. When the upper mediastinum is involved, retrosternal pain may be present and may radiate upward into the neck.3

Clinical presentation and outcome of the oesophageal rupture depends on the size, location and cause of injury, the presence of underlying oesophageal disease, and the interval between injury and treatment. We believe that, in our case, the absence of sepsis and the success of the antibiotic treatment were due to the very small size of the oesophageal lesion, which caused minimal contamination of the mediastinum. Although our case had a favourable outcome, Katsetos et al reported the case of a 70-year-old man with a history of fish bone ingestion and choking, who was discharged from the emergency room after normal laryngoscopic and oesophagram results. After 12 days he was brought back to the hospital with severe sepsis due to mediastinitis. No surgical procedure could be performed due to his unstable condition. Despite clinical treatment with antibiotics the patient died on the third day in hospital.4

Mortality rates of oesophageal perforation vary from series to series. In 1996, Bufkin et al, in a retrospective review of 66 patients, noted a mortality rate of 24.2%.5 More recent studies reveal better outcomes. Port et al described a 3.8% mortality rate among 26 patients.6 Bladergreon et al reported a 94% survival rate for patients with foreign body perforations.7

The oesophagus can be managed with primary closure, muscle flaps closure, exclusion and diversion, oesophagetomy or drainage. Recently, intraluminal stents and minimally invasive repairs with thoracoscopic surgery showed good results in selected patients.8^,9 The collection in the mediastinum usually requires surgical drainage by thoracotomy or video assisted thoracic surgery.10

In our case, the lesion was so small that it could not be visualised during endoscopy and so did not require any surgical procedure. The typical history of fish bone ingestion and choking a week before admission to the hospital, combined with the findings of the CT scan, enabled an empirical diagnosis of mediastinitis to be made. Mediastinum collection was also small and no surgical drainage was performed.

In conclusion, despite the fact that oesophageal perforation with mediastinis is a severe disease, highly associated with sepsis and mortality, there are possible cases of indolent forms that can be difficult to diagnose yet respond very well to antibiotic treatment, with careful observation.