Hospital: HOSPITAL UNIVERSITARIO PUERTO REAL
Nº: C2019-471
Aut@r o Autores: E. García Gámez, A. Luna Morales, V. Lorenzo Quesada, M. Perez Benitez.
Presentación
We report the case of a 38 -year-old woman without any personal antecedents. She was attended by the medical services after trying to commit suicide by consuming a huge quantity of benzodiazepines. She was performed a gastric lavage with activated carbon, and was administered iv naloxone and flumazenil as a treatment. After removing the nasogastric tube she started with anterior cervical inflammation, subcutaneous crackling and dysphonia. An esophageal perforation was suspected so a cervical and thoracic CT was solicited. The images showed an important subcutaneous emphysema, pneumomediastinum and some liquid collections in the deep cervical spaces. An endoscopy and a nasofibrolaryngoscopy were performed only finding in the latter one a bulging of the left pharyngeal wall and an inflammation of the ipsilateral piriform sinus. Blood tests showed leucocytosis with polymorphonuclear cells and a CRP elevation. Conservative treatment was chosen with empiric antiobiotherapy. During the hospitalisation the patient suffered a clinical worsening showing cervical pain, odynophagia and low-grade fever. The clinical evaluation showed a displacement of the left oropharyngeal and hypofaringeal wall with no compromise of the airway. A control CT was performed and it showed similar findings to the first CT with a little quantity of high-density. It was decided to perform a trans-oral and cervical drainage of the left parafaryngeal abscess. A big quantity of content was obtained and turned out to be activated carbon. The patient showed an important clinical improvement without symptoms and a fast radiologic response.
Discusión
The esophageal perforation is a serious complication with a high rate of mortality. Between its causes the most frequent ones are the iatrogenic, and among them the placement of feeding tubes. The clinical symptoms of a cervical esophageal perforation are cervical pain, dysphagia and fever.In what refers to the image tests, an esophagogram with hydrosoluble contrast helps us to determine the place and extension of the perforation, showing extraesophagic gas and contrast extravasation. The CT shows a better definition of the extraluminal manifestations like extraesophageal air, oral contrast extravasation and the existence of liquid collections near the oesophagus. There can also exist a diffuse infiltration of the mediastinum fat when a mediastinitis or esophago-pleural fistulas appear. Considering the patient’s situation and characteristics the treatment can be conservative or surgery-based depending on an individualised decision.
Conclusión
The esophageal perforation is a serious complication with a high rate of mortality. The image tests play an important role on its early diagnosis contributing to an early treatment and improving its prognosis.
Bibliografía
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