University of Tennessee Health Science Center College of Medicine Chattanooga, TN, United States
Peter DeLeeuw, DO, Aparna P. Shreenath, MD, PhD, George Philips, MD, Arslan Kahloon, MD University of Tennessee Health Science Center College of Medicine, Chattanooga, TN
Introduction: Esophageal perforations are rare occurrences with non-specific symptoms and high mortality rates. We present a case of a woman with high volume chest tube output secondary to esophageal perforation, likely resulting from chest tube placement and not identified on CT imaging.
Case Description/Methods: A 38 year old female with a history of schizoaffective disorder and twin pregnancy at 27 weeks presented to the ED with respiratory failure and septic shock. Initial workup found intrauterine fetal demise of one fetus and a right hydropneumothorax. A chest tube was placed with an initial output of 700ml of bloody brown fluid. Upon arriving to the ICU, a c-section was performed, and the patient was intubated. The chest tube continued to put out over 1L of thick green-yellow fluid every 24 hours. Pleural fluid cultures grew candida and MSSA. CT surgery performed a VATS procedure, but the chest tube continued to put out high volumes of fluid. GI was consulted at this time with concern for esophageal perforation due to the pleural fluid cultures, the color, and amount of chest tube output. On review of imaging, a CT showed the initial chest tube being placed far into the right lung. The CT was reviewed with radiology and no pneumomediastinum, perforation, or liver laceration were identified. Analysis of pleural fluid and imaging with oral contrast were recommended to rule out esophageal perforation. Pleural fluid came back positive for amylase (328) and bilirubin (2.8). The critical care team also placed methylene blue through the patient’s NG tube which resulted in blue chest tube output. An esophagram was performed which showed esophageal perforation with contrast pooling in the right lung. An EGD found a non-bleeding epithelialized perforation in the distal esophagus. A fully covered metal stent was placed. Two days later, a repeat esophagram was negative for a leak. The patient required additional cardiothoracic intervention but was able to be extubated and come off pressors shortly after stent placement.
Discussion: Although rare, esophageal perforation should be on the differential in patients with high volume chest tube output. Diagnosis can be difficult, but pleural fluid with cultures suggestive of esophageal flora, elevated amylase levels, or green color are all signs of a possible esophageal perforation. Esophageal perforation can be missed on imaging techniques such as CT, therefore esophagram is recommended and is the gold standard for identification.
Figure: A. CT showing chest tube placed far into right lung B. Esophagram showing esophageal perforation with contrast pooling in the right lung C. Non-bleeding epithelialized perforation in the distal esophagus (multiple arrows) next to GE junction (two arrows) D. A fully covered metal stent placed sealing esophageal perforation (perforation circled)
Disclosures: Peter DeLeeuw indicated no relevant financial relationships. Aparna Shreenath indicated no relevant financial relationships. George Philips indicated no relevant financial relationships. Arslan Kahloon indicated no relevant financial relationships.
Peter DeLeeuw, DO, Aparna P. Shreenath, MD, PhD, George Philips, MD, Arslan Kahloon, MD. P2447 - A Rare Case of Esophageal Perforation With High Volume Chest Tube Output Not Initially Seen on CT Imaging, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.