Endoscopic treatment of paraesophageal abscess in eosinophilic esophagitis after chest trauma

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BRIEF REPORTS

Endoscopic treatment of paraesophageal abscess in eosinophilic esophagitis after chest trauma Mikael Sawatzki, MD,1 Martin N. Stienen,2 Alex Straumann, MD,3 Christa Meyenberger, MD,1 Christian Öhlschlegel, MD,4 Janek Binek, MD1 St. Gallen, Switzerland

CASE REPORT A 19-year-old man was admitted with dysphagia, retrosternal pain, and fever after he was hit on the breastbone during an assault 10 days before. He experienced progressive chest pain despite treatment with a proton pump inhibitor. Laboratory test analyses showed signs of inflammation, with a leucocyte count of 11,400/mm3 (normal 4.0-10.0 mm3) and C-reactive protein level of 201.8 mg/L (normal ⬍ 8 mg/L). CT revealed a 12-cm, paraesophageal abscess, with enlarged mediastinal and infradiaphragmatic lymph nodes and mediastinitis (Fig. 1). Upper endoscopy indicated a 7-cm–long narrowing of the esophagus with a pus-draining fistula located 30 cm from the teeth (Fig. 2). Endoscopic fistulotomy was performed along a guidewire. The cavity was generously rinsed with saline solution, and a nasogastric tube was inserted; proton pump inhibitor therapy, antibiotics, and parenteral nutrition were initiated. The patient’s clinical condition improved rapidly, and CT 5 days later demonstrated abscess reduction. Microbiologic examination revealed group G streptococci. No other endoscopic interventions were needed. Esophagoscopy 5 weeks later revealed a feline esophagus. Histologic examination of 12 biopsy samples from all over the esophagus demonstrated eosinophilic infiltration (⬎30 eosinophils/high-power field on all sites; range 2545) (Fig. 3). The diagnosis of eosinophilic esophagitis (EoE) was established, and treatment with oral topical corticosteroids (fluticasone propionate) was initiated. Clinical and endoscopic follow-up was uneventful and lacked any signs of esophageal dysfunction.

Figure 1. Esophageal abscess as initially diagnosed by CT imaging. Nearly complete occlusion of the esophagus by the abscess (*) in the axial view.

Figure 2. Endoscopic view of the fistulotomy, with placement of an endoclip marking the distal end of the opening.

DISCUSSION We report on a young male patient experiencing a paraesophageal abscess likely caused by trauma-induced, transmural esophageal perforation. The subsequent diagnostic work-up demonstrated that this life-threatening event occurred in an esophagus affected by eosinophilic inflammation. The patient fulfilled clinical, endoscopic, and histologic criteria of EoE.1 This severe esophagus breach must therefore be considered as a complication of pre-existing, undiagnosed EoE. www.giejournal.org

Unbridled EoE is known to lead to esophageal remodeling, with fibrosis and abnormal fragility of the wall.2 Transmural esophagus perforations are well-known complications of EoE that are either retching-induced (Boerhaave syndrome) or procedure-induced.3 Notably, this is the first published case, to our knowledge, to show that in patients with EoE, even nonpenetrating chest trauma can lead to transmural esophagus perforation. Gastroenterologists and surgeons should bear this risk in mind, because Volume xx, No. x : 2011 GASTROINTESTINAL ENDOSCOPY 1

Brief Reports

Abbreviation: EoE, eosinophilic esophagitis.

REFERENCES

Figure 3. Increase in eosinophilic granulocytes in the mucosa of the distal esophagus (H&E, orig. mag. ⫻ 40).

patients with EoE are often young and mobile and because chest traumas occur frequently in traffic accidents. To date, only a small minority of EoE-related esophageal perforations have required surgery.4 In selected cases, invasive endoscopic treatment of mediastinal abscesses should be considered a valid alternative to surgery.5 DISCLOSURE All authors disclosed no financial relationships relevant to this publication.

2 GASTROINTESTINAL ENDOSCOPY Volume xx, No. x : 2011

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1. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011;128:3-20. 2. Aceves SS, Newbury RO, Dohil R, et al. Esophageal remodeling in pediatric eosinophilic esophagitis. J Allergy Clin Immunol 2007;119:206-12. 3. Straumann A, Bussmann C, Zuber M, et al. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008;6:598-600. 4. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007;133:1342-63. 5. Stergiou N, Vogel B, Riphaus A, et al. Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series. Gastrointest Endosc 2005;62:344-9.

Unit of Gastroenterology (1), Department of Medicine, Kantonsspital St. Gallen, St. Gallen, Department of Medicine (2), Kantonsspital St. Gallen, Rorschach, Department of Gastroenterology (3), University Hospital Basel, Basel, Department of Pathology (4), Kantonsspital St. Gallen, St. Gallen, Switzerland. Reprint requests: Mikael Sawatzki, MD, Department for Gastroenterology/ Hepatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007 St. Gallen, Switzerland. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.08.041

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