Conservative management of esophageal perforation due to external air-blast injury: a case report and literature review

Background

Esophageal perforation is a life-threatening clinical situation, timely diagnosis is difficult and scientific therapy experiences for this condition are lacking [Søreide and Viste, 2011]. Esophageal perforation caused by iatrogenic or other reasons has been reported frequently, however, barotraumatic injury caused by external air-blast is rare. Only four cases were found in the English literature when searched by Roan and Wu in 2010, and 11 cases were found in a perusal of the English and Chinese literature up to 2013 (Table 1) [Roan and Wu, 2010; Wu et al. 2011; Zhu et al. 2009; Zhou, 2007; Zhang et al. 2006; Li et al. 2000; Guth et al. 1991; Michel et al. 1981; Majeski and MacMillan, 1979; Volk et al. 1955]. Herein, we report a case of a patient with esophageal perforation following an injury caused by a gas-tank explosion who recovered satisfactorily after conservative management. The diagnosis and therapy strategy of this condition are discussed.

Table 1.

Esophageal perforation or rupture caused by external air-blast injury.

Reported year	Age (years)	Gender	Presentation	Chest radiography or computed tomography scan	Interval to diagnosis (h)	Location	Management	Outcome	References
This case	20	Remale	Chest pain	Mediastinum pneumothorax and subcutaneous emphysema	42	Middle	Conservative	Survived
2011	28	Female	Chest pain dyspnea	Pneumothorax	8	Lower	Operative	Survived	3
2010	31	Male	Chest pain dyspnea	Pneumothorax	84	Lower	Operative	Survived	2
2009	34	Male	Dyspnea	Pneumothorax	72	Lower	Operative	Survived	4
2007	20	Male	Dyspnea	Pneumomediastinum	96	Middle	Operative	Died	5
2006	22	Male	Chest pain dyspnea	Pneumothorax and pneumomediastinum	120	Lower	Conservative	Survived	6
2000	18	Male	Chest pain dyspnea	Pneumothorax	—	Lower	Operative	Survived	7
2000	36	Male	Chest pain dyspnea	Pneumothorax	—	Lower	Operative	Survived	7
1991	35	Male	Dyspnea	Pneumothorax	24	Middle	Operative	Survived	8
1980	_	_	_	_	24	Lower	Operative	Survived	9
1979	15	Male	Chest pain dyspnea	Pneumothorax	48	Lower	None	Died	10
1955	22	Female	Dysphagia neck pain and hemoptysis	Pneumothorax and subcutaneous emphysema	240	Cervical	Operative	Survived	11

Case presentation

The patient was a fit and healthy 20-year-old woman who worked in a shoe company. On 31 August 2013, while she was working, a large tank containing high-pressure gas exploded in front of her. She immediately lost consciousness. About 2–3 min later, she regained consciousness and complained of severe chest pain and dizziness. The woman was brought to the emergency department of our hospital 1 h after the accident.

Upon admission, the patient did not present with dyspnea or cyanosis. Her vital signs were stable, with a respiratory rate of 22 /min, blood pressure of 100/70 mmHg, heart rate of 100/min, and a body temperature of 36.7°C. However, her left-sided breath sounds were decreased remarkably. A computed tomography (CT) scan was performed immediately and the diagnosis of pneumothorax with pneumomediastinum and subcutaneous emphysema was confirmed (Figure 1). Thus, an emergency left-tube thoracostomy was performed. In addition, esophageal perforation was strongly suspected but not shown on a methylene blue swallow. A contrast study of the esophagus was performed immediately with diatrizoate meglumine and no leakage of contrast material from the esophagus was observed (Figure 2). On 2 September 2013, an upper gastrointestinal (GI) tract endoscopy revealed an esophageal ulcer 25 cm from the incisors (Figure 3a), while bronchoscopy illustrated that there was no tracheal fistula. From these findings, it was thought that the esophageal perforation closed naturally soon after this condition occurred.

Figure 1.

Chest computed tomography scan of the patient shows a left pneumothorax and pneumomediastinum.

Figure 2.

No leakage of contrast material from the esophagus was observed by chest computed tomography scan with diatrizoate meglumine swallow.

Figure 3.

(a) gastrointestinal tract endoscopy revealed an esophageal ulcer 25 cm from the incisors; (b) a repeated upper gastrointestinal tract endoscopy revealed a rent scar of 1.5 cm in the esophagus.

The patient was managed conservatively. Oral nutrition was prohibited and parenteral nutrition was used to maintain the patient’s nutritional status as soon as esophageal perforation was suspected. The proton-pump inhibitor, omeprazole, was given intravenously. Meropenem 1.0 g as a 3-h infusion every 8 h was used to treat infections until there was no fever and inflammatory markers (white blood cells, procalcitonin, and C-reactive protein) returned to normal levels. The patient was discharged 26 days after admission. On 15 October 2013, an upper GI endoscopy revealed a rent scar of 1.5 cm in the esophagus without esophageal stenosis (Figure 3b). A repeated CT scan was within normal limits (Figure 4).

Figure 4.

Repeated chest computed tomography scan was within normal limits.

Conclusion

A few cases of esophageal perforation have been reported as a result of a sudden release of high-pressure air into the esophagus via the mouth [Lee and Lim, 2005]. However, esophageal perforation caused by external air-blast injury is extremely rare with only 11 reported cases in the English and Chinese literature. The very low incidence of esophageal perforation by barotraumas makes it difficult for individual doctors to gain clinic experience to give a timely and accurate diagnosis [Roan et al.2010; Wu et al. 2011].

Symptoms of esophageal perforation vary depending on the cause, location, as well as the time of occurrence. As shown in Table 1, chest pain and dyspnea are the most common symptoms of esophageal perforation caused by external air-blast injury. However, the common presenting symptoms are not specific for esophageal perforation. Diagnosis of an esophageal perforation mainly relies on radiographic evidence. The esophagogram is considered to be the gold standard examination with which to establish the diagnosis of esophageal lesions and can reveal a contrast leak in most cases of esophageal perforation [Hasimoto et al. 2013; Kiss, 2008]. It is important to mention that esophagograms can produce false negatives by up to 10–25% [Flynn et al. 1989]. In the case presented here, no leakage of contrast material from the esophagus was observed by CT with diatrizoate meglumine swallow. CT findings include esophageal wall thickening, extraluminal gas, and abscessed cavities adjacent to the esophagus highly suggestive of esophageal perforation [Wu et al. 2007]. All of the 11 reported esophageal perforations caused by external air-blast injury presented with pneumothorax or pneumomediastinum. In those patients, flexible endoscopy should be considered to provide additional information [Søreide et al. 2011]. In the case presented here, an upper tract GI endoscopy revealed a diagnosis of perforation of the esophagus. It should be noted that pneumomediastinum and pneumothorax can also be caused by lung injury after an external air-blast.

The appropriate management of esophageal perforation is a controversial issue. Operative management was the mainstay of the treatment performed in 9 of the 11 cases of esophageal perforation caused by an external air-blast injury. However, there has been a recent trend toward more nonoperative management [Søreide et al. 2011]. According to the criteria defined by Cameron and colleagues [Cameron et al. 1979] and later modified by Altorjay and colleagues, conservative management can be applied to selected patients with suspected or limited perforation, perforation not in the abdomen, contained perforation in the mediastinum, content of the perforation draining back to the esophagus, perforation does not involve neoplasm or obstruction of the esophagus, there is an absence of sepsis symptoms and signs [Altorjay et al. 1997]. Our patient was managed conservatively although she had sepsis symptoms. She was treated with chest-tube drainage and intravenous broad-spectrum antibiotics until signs of inflammation disappeared. To maintain the patient’s nutritional status, parenteral nutrition or enteral tube feeding can be used until oral feedings can be initiated and effectively sustained. After conservative management for 26 days, the patient was discharged. A repeated endoscopic and CT scan revealed that this patient recovered satisfactorily.

In conclusion, esophageal perforation caused by external air-blast injury is a rare and life-threatening clinical situation. Considering esophagograms have a significant rate of false-negative results, other technologies including flexible endoscopy should be considered to provide additional information. Conservative management is a safe and effective strategy for an esophageal perforation which has closed naturally.

Consent

The patient gave her consent for the case report to be published. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.