Naba Saeed, MD
Ann Arbor, Michigan
Naba Saeed, MD1, Zarak H. Khan, MD2, Mohammad Muzaffar, MD3, Mihajlo Gjeorgjievski, MD4, Sahla Hammad, MD5, Humza Khan, MD6, Syed Tasleem, MD7
1University of Michigan Health System, Ann Arbor, MI; 2St. Mary Mercy Hospital, Livonia, MI; 3Beaumont Health, Wayne, MI; 4Beaumont Health, Royal Oak, MI; 5St. Joseph Mercy Oakland Hospital, Pontiac, MI; 6St. Joseph Medical Center, Ypsilanti, MI; 7Baylor College of Medicine, Houston, TX
Introduction: Esophageal variceal bleeding is one of the leading causes of death in patients with cirrhosis, requiring rapid endoscopic intervention and vasoactive medication administration. When this fails, balloon tamponade using Sengstaken–Blakemore (SB) tube is an effective temporizing measure in up to 90% of patients. However, it can result in esophageal perforation, with potentially fatal septic mediastinitis. Mediastinitis from esophageal perforation carries mortality rates as high as 40-67%, with mortality rate increasing as time to perforation detection increases. Hence a high level of suspicion and rapid identification are key.
Case Description/Methods: A 56 year old male with history of decompensated Hepatitis C related cirrhosis, recurrent variceal bleeds and portal vein thrombosis (on warfarin), presented with massive hematemesis due to variceal bleed. Despite endoscopy (EGD) with banding, re-bleeding occurred, with rapid drop in hemoglobin from 9 to 5 g/dl. Despite multiple attempts, SB tube was unsuccessful due to resistance. Therefore, the patient was emergently transferred to a tertiary care center for specialist management. Upon presentation, he was found to be in fluid/blood unresponsive shock, requiring high dose vasopressor support. An emergent EGD revealed a 1 cm esophageal perforation above the gastroesophageal junction. CT chest revealed pneumomediastinum. He underwent esophageal stent placement 24 hours later, and was concomitantly treated with antibiotics, antifungals, vasopressors and chest tube insertion for mediastinitis. He slowly stabilized following these interventions, and within 1 week was transferred out of the ICU.
Discussion: In patients with fluid/blood unresponsive shock following esophageal manipulation with an SB tube, a high level of suspicion for esophageal perforation and mediastinitis should be maintained. In the past, Xray and esophagogram were thought to be helpful in establishing the diagnosis, however, it is now recognized that going straight to contrast-enhanced CT thorax has the highest yield and will establish diagnosis expediently. This is a necessity, as studies have shown a dramatic reduction in mortality if the diagnosis is made within the first 24 hours, with subsequent initiation of antibiotics and antifungals. Lastly, early consideration for esophageal stenting has also shown to reduce mortality, by tamponading the bleeding varices as well as the perforation.
Citation: Naba Saeed, MD; Zarak H. Khan, MD; Mohammad Muzaffar, MD; Mihajlo Gjeorgjievski, MD; Sahla Hammad, MD; Humza Khan, MD; Syed Tasleem, MD. P1225 - ESOPHAGEAL PERFORATION FROM BLAKEMORE TUBE USE RESULTING IN MEDIASTINITIS: IMPORTANT CLINICAL PEARLS TO REDUCE MORTALITY. Program No. P1225. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.