Conservative management of emphysematous esophagitis—a case report

Introduction

Emphysematous esophagitis is a very rare and severe disease with only a few case reports (1,2). In one paper, there was a report on emphysematous esophagitis occurring after hydrogen peroxide (HP) ingestion (1). In another paper, a case of emphysematous esophagitis was reported with no clear preceding factors other than acupuncture at anterior cervical region (2).

In this paper, we report a case of emphysematous esophagitis in a 65-year-old female patient with no history of trauma or toxic ingestion. In the early stage of the disease, the patient’s esophageal necrosis was so severe that even an attempt to enter the endoscope was not possible, but our patient recovered with appropriate conservative treatment and was discharged. We present this article in accordance with the CARE reporting checklist (available at https://med.amegroups.com/article/view/10.21037/med-24-16/rc).

Case presentation

A 65-year-old woman was admitted to Inje University Sanggye Paik Hospital with general weakness. She complained abdominal discomfort, nausea and loss of appetite for 1 week. And she also complained chest discomfort started 3 days ago. She had a history of atrial fibrillation and mitral stenosis and was taking warfarin. Initial laboratory studies revealed increased white blood cell 13,150/µL, C-reactive protein 23.1 mg/dL, and prolonged prothrombin time 31.9 (international normalized ratio 3.18). These findings suggested that there was some type of inflammation in the body. For further evaluation chest and abdominal radiographs were obtained. A chest radiograph showed abnormal air shadows in upper mediastinum (Figure 1A). An abdominal radiograph also showed abnormal air shadows in the left upper quadrant of the abdomen (Figure 1B). Thus, the patient underwent chest and abdomen computed tomography (CT) scan with contrast enhancement (CE). Chest CT scan showed intramural gas in the mural layer of the entire esophagus and stomach (Figure 2A,2B). Thus, emphysematous esophagitis and gastritis were suspected. In addition, there were no findings of pneumomediastinum or portal vein gas, and there was no intraperitoneal free air.

Figure 1 Plain radiographs of a patient with emphysematous esophagitis with gastritis taken in the emergency room. There are liner or dot-like air density gathered in the upper mediastinum (arrows) on a chest radiograph (A). There are air shadows along the border of the stomach (arrows) on an abdominal radiograph (B).

Figure 2 CT scans of a patient with emphysematous esophagitis with gastritis taken in the emergency room. Axial (A) and coronal (B) view of contrast enhanced chest CT show intramural gas of the esophagus (arrows). CT, computed tomography.

Endoscopy was attempted for a more accurate diagnosis. Bluish-gray mucosa was observed from the entrance to the esophagus and was judged to be necrosis. Therefore, the examination was discontinued due to the risk of perforation. On blood culture, Klebsiella pneumoniae and Pseudomonas aeruginosa were grown. The patient received conservative management with proton pump inhibitors (PPIs), broad spectrum antibiotic therapy, fluid resuscitation and total parenteral nutrition (TPN). On follow-up CE chest CT scan, obtained 12 days later, intramural gas in esophagus and stomach was decreased (Figure 3A).

Figure 3 Follow-up CT scan and chest radiograph of a patient with emphysematous esophagitis with gastritis. A follow-up chest CT (A) performed 12 days later shows that all intramural air in the esophagus had disappeared, and there was mild wall thinning and fluid retention in the esophagus (arrow). Bilateral pleural effusion is also observed. A follow-up chest radiograph obtained 2 months later (B) shows no unusual findings other than subsegmental atelectasis in the left lower lung zone. CT, computed tomography.

The patient received antibiotic treatment for about a month, and then went on a diet. The patient’s symptoms improved and she was discharged. A chest CT performed on the 12^th day of hospitalization revealed a thrombus in the left atrium (LA), and the patient was discharged with a prescription for anticoagulants. Two months after discharge, the patient returned to Inje University Sanggye Paik Hospital with hematemesis. Plain chest radiograph before discharge showed improved air shadows in upper mediastinum and upper abdomen (Figure 3B).

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of this case report and accompanying images was waived from patient consent according to the Sanggye Paik Hospital institutional review board.

Discussion

Emphysematous esophagitis is thought to be an infection of the esophageal wall caused by gas forming bacteria and is usually accompanied by emphysematous gastritis (1).

If there is air shadow within the esophageal or stomach wall but there is no sign of systemic toxicity, this should be classified as esophageal or gastric emphysema as it is self-limiting (3). Endoscopy shows erosion of the esophageal wall or severe necrosis, similar to the reported cases. Plain chest X-ray shows additional mediastinal air shadows other than those caused by the esophageal lumen along the path of the esophagus. On CT, it is more clearly visible as circular or linear air density located within the esophageal wall.

The mortality rate of emphysematous gastritis is 62%, and increases to 75% when portal vein gas is present (4). The mortality rate of emphysematous esophagitis itself is unknown, but since it is mainly accompanied by emphysematous gastritis, it can be assumed to be similar to or slightly higher.

If emphysematous esophagitis is detected early, it is possible to try conservative management with TPN and broad-spectrum antibiotics to provide adequate nutrition while resting the gastrointestinal system (1,2). However, when esophageal or gastric perforation occurs, surgical management must be performed first, followed by supportive management (4).

Conclusions

In conclusion, emphysematous esophagitis is a severe disease, but if the clinical and radiological findings are known, such patients can be detected quickly and adequate therapy can be started.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://med.amegroups.com/article/view/10.21037/med-24-16/rc

Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-24-16/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-24-16/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of this case report and accompanying images was waived from patient consent according to the Sanggye Paik Hospital institutional review board.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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