Ocala Regional Medical Center Ocala, FL, United States
Randa Abdelmasih, MD1, Ramy Abdelmaseih, MD1, Mohammed Ansari, MD2, Bilal Ashraf, MD1, Niti Aggarwal, MD1 1Ocala Regional Medical Center, Ocala, FL; 2University of Central Florida College of Medicine, Ocala, FL
Introduction: Esophageal diverticulum is an outpouching of the esophageal mucosa that is usually asymptomatic and relatively rare. It accounts for about 1% of all barium gastrointestinal radiographs and less than 5% of those who present with dysphagia. Patients typically present with regurgitation, dysphagia, halitosis, recurrent heartburn, chronic cough or recurrent episodes of pneumonia. Here we present a rare case of post-radiation induced esophageal diverticulum appearing as perforation in all radiologic studies including barium swallow which was a diagnostic conundrum.
Case Description/Methods: A 62-year-old male with a history of lung and vocal cords squamous cell carcinoma vocal status post-radiation (last radiotherapy was 1 year prior) on chemotherapy presented due to a fall. Patient reported chest pain for 2 weeks. Vital signs included temp 101.2 heart rate 119, with chest tenderness and decreased breath sounds on exam.
As part of trauma protocol, cervical CT with contrast showed proximal thoracic esophagus injury with gas extending into the C7-T1 level. Cervical MRI WO contrast was consistent with CT findings of possible esophageal perforation.
CT chest W/WO contrast showed an air-fluid collection in posterior para-esophageal mediastinum concerning for esophageal perforation and para-esophageal abscess.
Empiric antibiotics and nothing per mouth were started. X-Ray Gastrographin Swallow showed possible esophageal perforation within the upper thoracic region with posterior para esophageal contrast accumulation and paraspinal abscess.
Gastroenterology service was consulted for further evaluation and Esophagogastroduodenoscopy was done which showed a 4 cm excavated diverticulum with scar tissue and no evidence of perforation. Diet was advanced and was well tolerated. The patient was discharged in clinically stable condition.
Discussion: Radiotherapy of the head, neck, and chest puts the esophagus at risk of radiation-induced injury due to its proximity to these structures. The most common post-radiation complications includes esophagitis, stricture, and rarely bleeding or perforation. What makes our case special is that our patient developed a diverticulum mimicking esophageal perforation. All imaging modalities were further misguiding because of post-radiation mediastinal and spinal changes as spinal abscess/osteomyelitis, pleural effusion, and air in para-spinal tissue. Endoscopic evaluation in our case was the diagnostic modality of choice to rule out esophageal perforation and manage accordingly.
Figure: Figure (1): Cervical CT arrow showing questionable injury to the proximal thoracic esophagus at the thoracic inlet level with prevertebral soft tissue mild swelling with gas extending into the C7-T1 level. Figure (2): CT chest W contrast arrow showing Prevertebral gas seen in the thoracic inlet concerning for sophageal perforation as a possibility. Figure (3): Thoracic MRI showing gas in the anterior epidural space and posterior para esophageal space. Figure (4): Oral Gastrographin study, arrow showing contrast extravasation and accumulation within the upper thoracic region concerning for esophageal perforation.
Disclosures: Randa Abdelmasih indicated no relevant financial relationships. Ramy Abdelmaseih indicated no relevant financial relationships. Mohammed Ansari indicated no relevant financial relationships. Bilal Ashraf indicated no relevant financial relationships. Niti Aggarwal indicated no relevant financial relationships.
Randa Abdelmasih, MD1, Ramy Abdelmaseih, MD1, Mohammed Ansari, MD2, Bilal Ashraf, MD1, Niti Aggarwal, MD1. P1384 - A Unique Case of Post-Radiation Esophageal Diverticulum Mimicking Esophageal Perforation - A Diagnostic Conundrum, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.