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Aortic Pseudoaneurysm Secondary to Mediastinitis due to Esophageal Perforation.

1. Case Report

A 54-year-old female patient was admitted to the emergency department with an 8-day history of epigastric pain that began one day after eating fish. She consulted at another institution five days before, where she underwent esophagogastroduodenoscopy that did not reveal any foreign body or esophageal abnormalities. The symptoms got worse despite antacids and analgesic therapy so she consulted at our institution. She has a personal history of type 2 diabetes mellitus. The physical examination revealed tachycardia and intense epigastric pain on palpation.

The hepatic biochemistry and blood amylase levels were within the normal range. A complete blood count documented leukocytosis (18.500 cells/mm3) with neutrophilia (85.3%) and positive C-reactive protein (161.8 mg/L).

Contrast enhanced thoracic and abdominal Computed Tomography was performed. The CT scan showed the presence of a pseudoaneurysm of the thoracic aorta, thickening of the esophageal wall, and abnormal density of the mediastinal fat with air bubbles within it that suggested mediastinitis. There was no evidence of contrast material extravasation from the esophageal lumen (Figure 1).

An aortic endoprosthesis was placed and a second CT scan was performed using oral hydrosoluble contrast material. Leakage of the contrast material to the posterior mediastinum, approximately 6 cm below the carina, was clearly seen (Figure 2).

A second esophagogastroduodenoscopy confirmed an esophageal perforation. An esophageal stent was placed. The patient was then taken to surgery (right posterolateral thoracotomy) to drain the mediastinitis, debride the necrotic tissue, and perform transposition of a pedicled intercostal muscle flap to cover the esophageal defect. The patient had a satisfactory evolution.

2. Discussion

Esophageal perforations can be spontaneous or secondary to trauma, iatrogenic lesions, foreign body ingestion, and tumoral processes [1, 2]. The presence of foreign bodies is a frequent condition [3]. Ingested sharp-pointed objects lodged in the esophagus are a medical emergency. These elements may pass through the esophagus without affecting the esophageal structure (80% of the cases) but 10 to 20% of ingested foreign bodies will require endoscopic removal [4, 5]. Ingested foreign bodies are responsible for 80% of cervical perforations [6]. Fish bones are a predominant cause (60%) [7-9], followed by chicken bones (16%) and other objects such as coins [9,10]. Perforation occurs in up to 4% of those patients [3, 7, 8,11], with 22% mortality according to a series of 511 patients [1,11,12] and 20% according to Brinster and colleagues [13].

Another less frequent cause of esophageal perforation (0.25%) is those lesions that occur during endoscopic removal of ingested foreign bodies.

Esophageal perforations due to ingestion of a foreign body can cause complications like mediastinal infection, vascular trauma (aortoesophageal fistula, pseudoaneurysm), paraesophageal abscess, tracheoesophageal fistula, pneumomediastinum, pneumothorax, pericarditis, and some others [10, 11, 14-17]. Foreign bodies may migrate to adjacent structures including the thyroid gland [9] forming abscesses in the deep neck [7].

Vascular structures such as the aorta, subclavian artery, internal carotid artery, and the internal jugular vein [7] may be affected [1]. The lesions that affect the aortic wall may be secondary to direct puncture of the wall by the foreign body or due to the extension of the mediastinal inflammatory process with an aortic rupture contained by the adjacent soft tissues and the inflammatory exudate (pseudoaneurysm). In some cases there can be direct communication between the esophagus and the aorta (aortoesophageal fistula) [3, 7]. Eventually, the site of esophageal perforation is occluded by a clot and hematoma that leads to partial tamponade that prevents subsequent bleeding [3].

The most common site of aortic complications is located 1to5 cm distal to the origin of the left subclavian artery [1820]. These vascular complications have severe mortality and morbidity [7,18,19], which may develop after weeks or years with an invariable fatal ending [11].

In order to compile this review article we conducted a selective literature research in PubMed. 81 articles in English matched our search terms "foreign body ingestion AND mediastinitis, aortic pseudoaneurysm AND aortoesophageal fistula". After excluding articles of aortoesophageal fistula, we were left with 8 case reports. All of these cases had clinical features and imaging findings of mediastinitis with secondary aortic pseudoaneurysm. The causes of perforation were fish bone ingestion as the most common, followed by chicken bone ingestion and one case of complication after esophageal botulinum toxin injection for achalasia. All patients consulted with similar symptoms including hematemesis, fever, dysphagia, odynophagia, and systemic inflammatory response syndrome. All consulted the emergency room 3 to 12 days after the perforation occurred (Table 1).

Radiographic studies are necessary to confirm the diagnosis of foreign bodies and esophageal perforation. Perforation of the cervical esophagus can lead to the presence of prevertebral air bubbles and soft tissue thickening. In 90% of thoracic esophagus perforation presence of pleural effusion, pneumothorax and hydropneumothorax can be seen [6, 21]. Right-sided pleural effusion occurs if the perforation is located in the middle third of the esophagus. Leftsided pleural effusions are commonly associated with distal esophageal perforation. Esophageal perforation may also be diagnosed by the presence of food particles, pH less than 6.0, or the presence of an elevated amylase level in the pleural fluid analysis [6, 21].

In the setting of foreign bodies, CT scan is useful in those cases with suspected complications (e.g., perforation) or when it is necessary to identify the foreign body before esophagogastroduodenoscopy [5]. Cervical, thoracic, and abdominal CT scan with oral and intravenous contrast is currently the modality of choice in the assessment of esophageal perforation with a sensitivity of 92 to 100% [6]. This imaging method allows evaluation of the extent of the perforation based on associated findings such as mediastinitis, pleural effusion, extrapleural collections, and intraperitoneal effusion [6]. Extraluminal air is the most common CT finding in esophageal perforation, occurring in almost 92% of cases [21].

Esophagography is useful in identifying the perforation when extravasation of hydrosoluble contrast material occurs allowing also establishing if the leak is contained or not [6]. It has a sensitivity of 50% for the detection of cervical esophageal perforation and of 75 to 80% for the detection of thoracic esophageal perforation; however, it has an overall false-negative rate of 10% [6]. If the first esophagography is negative but there are strong clinical signs and symptoms of perforation or a suspicion of a fistulous tract, a second esophagography is advised in the following hours [6].

Esophagogastroduodenoscopy has a sensitivity of nearly 100% and a specificity of 83% for the detection of esophageal perforation [21]. However, it is not recommended as the primary diagnostic method in esophageal perforation because it may miss a perforation hidden in a mucosal fold and has the potential to enlarge a small mucosal or submucosal tear turning it into a large perforation during air insufflation process [21].

As relevant facts in our case, the initial esophagogastroduodenoscopy and esophageal CT scan did not show an esophageal perforation. Although the initial vascular complication was managed, the alterations associated with the mediastinitis made a second CT evaluation mandatory, which showed the perforation and enabled the appropriate treatment of the underlying condition (esophageal perforation with secondary mediastinitis).

3. Conclusion

Among the possible complications of mediastinitis secondary to esophageal perforation, vascular lesions must be considered (pseudoaneurysm and aortoesophageal fistula), which have a high morbimortality. Oral and intravenous enhanced CT is the study of choice to diagnose esophageal perforation and identify associated complications.

http://dx.doi.org/10.1155/2016/7982641

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

References

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[9] H. D'Costa, F. Bailey, B. McGavigan, G. George, and B. Todd, "Perforation of the oesophagus and aorta after eating fish: an unusual cause of chest pain," Emergency Medicine Journal, vol. 20, no. 4, pp. 385-386, 2003.

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[24] K. J. Sia, G. D. Ashok, F. M. A. Ahmad, and C. K. L. Kong, "Aorto-oesophageal fistula and aortic pseudoaneurysm caused by a swallowed fish bone," Hong Kong Medical Journal, vol. 19, no. 6, pp. 542-544, 2013.

Claudia Patricia Zuluaga, (1) Felipe Aluja Jaramillo, (2) Sergio Andres Velasquez Castano, (3) Aura Lucia Rivera Bernal, (1) Julio Cesar Granada, (1) and Jorge Alberto Carrillo Bayona (1)

(1) Hospital Universitario Mayor, Mederi, Bogota, Colombia

(2) FundaciOn Universitaria Sanitas, Bogota, Colombia

(3) Universidad del Rosario, Bogota, Colombia

Correspondence should be addressed to Jorge Alberto Carrillo Bayona; jacarriliob@unal.edu.co

Received 15 October 2015; Accepted 14 January 2016

Academic Editor: Vincent Low

Caption: Figure 1: (a) Axial enhanced CT scan. Mediastinal collection with air bubbles within it (white arrow). (b) Axial contrast enhanced CT scan. Pseudoaneurysm of the thoracic aorta (white arrow).

Caption: Figure 2: CT scan using oral hydrosoluble contrast material: (a) axial and (b) coronal reconstruction. (a) There is leakage of the contrast material from the esophagus to the posterior mediastinum (white arrow); the aortic stent was placed demonstrating that the esophageal wall is perforated. (b) Mediastinal collection with air bubbles within it (white arrow), surrounding the aorta with the stent placed in an adequate position.
Table 1: Foreign body and false aneurysm Pub Med search results.

Authors              Country     Sex   Age       Cause of
                                                perforation

Chao et al. [2]     Australia     M    76 y     Esophageal
                                              botulinum toxin
                                               injection for
                                                 achalasia

Chen et al. [14]      China       F    57 y      Fish bone

Chen et al. [14]      China       M    54y       Fish bone

Choi et al. [22]   South Korea    M    31 y      Fish bone

Chen et al. [23]      China       M    22 y    Chicken bone

Kunishige et al.      Japan       F    79 y      Fish bone
[1]

Sia et al. [24]     Malaysia      M    54 y      Fish bone

Sica et al. [17]     United       F    57 y      Fish bone
                     Kingdom

Authors                 T         Signs and symptoms

Chao et al. [2]       1 week      Chest pain, SIRS

Chen et al. [14]      6 days      Chest discomfort,
                                  chills, emesis,
                                  dysphagia, SIRS

Chen et al. [14]      6 days      Chest pain,
                                  hematemesis, SIRS

Choi et al. [22]     3 days       Fever
                    after fish
                   bone removal

Chen et al. [23]      1 week      Chest discomfort,
                                  hematemesis,
                                  leukocytosis

Kunishige et al.     11 days      Hematemesis, SIRS,
[1]                 after fish    positive PCR
                   bone removal

Sia et al. [24]       1 week      Hematemesis,
                                  odynophagia,
                                  dysphagia, fever

Sica et al. [17]      1 week      Chest pain, SIRS,
                                  positive PCR

Authors            Imaging findings         Treatment

Chao et al. [2]    Pseudoaneurysm of the    Endovascular stent
                   descending aorta with    graft, antibiotics
                   mediastinal abscess

Chen et al. [14]   Pseudoaneurysm in the    Antibiotics, resection
                   aortic isthmus,          of the pseudoaneurysm,
                   mediastinal abscess,     resection of the
                   bilateral pleural        esophagus
                   effusion

Chen et al. [14]   Pseudoaneurysm in the    Endovascular stent
                   aortic isthmus,          graft, antibiotics,
                   mediastinal abscess,     bilateral thoracostomy
                   bilateral pleural
                   effusion

Choi et al. [22]   Aortic rupture           Endovascular stent
                                            graft, esophageal
                                            resection

Chen et al. [23]   Esophageal-              Endovascular stent
                   mediastinal fistula      graft, esophageal
                   surrounded by            stent, mediastinal
                   inflammatory exudate     debridement
                   Pseudoaneurysm of the
                   descending aorta

Kunishige et al.   Pseudoaneurysm of the    Esophageal hemostasia,
[1]                aortic arch with no      antibiotics,
                   fistulous tract with     thoracotomy with
                   the esophagus            mediastinal
                                            debridement; the space
                                            was filled with
                                            omentum from colon and
                                            stomach

Sia et al. [24]    Saccular outpouching     Endovascular stent
                   (pseudoaneurysm) of      graft, antibiotics
                   the descending aorta
                   Mediastinal abscess

Sica et al. [17]   Abscess in the           Antibiotics,
                   superior mediastinum,    thoracotomy with
                   contrast leakage from    debridement of the
                   the aorta into the       mediastinal tissue,
                   mediastinum              aortic homograft
                                            patch, resection of
                                            the esophagus

Authors            Follow-up

Chao et al. [2]    Discharge, follow-up
                   for 4 months with no
                   symptoms

Chen et al. [14]   Discharge, but suicide
                   a year later

Chen et al. [14]   Discharge, follow-up
                   for 2 months with no
                   symptoms

Choi et al. [22]   Discharge, follow-up
                   for 4 months with no
                   symptoms

Chen et al. [23]   Discharge, the
                   esophageal stent was
                   removed 80 days after
                   surgery; follow-up for
                   6 months with no
                   symptoms

Kunishige et al.   Discharge, follow-up
[1]                for 2 months with no
                   symptoms

Sia et al. [24]    Esophageal
                   reconstruction was not
                   possible because the
                   patient died due to
                   sepsis

Sica et al. [17]   Discharge, follow-up
                   for 12 months with no
                   symptoms

T: time from perforation to emergency room.
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Title Annotation:Case Report
Author:Zuluaga, Claudia Patricia; Jaramillo, Felipe Aluja; Castano, Sergio Andres Velasquez; Bernal, Aura L
Publication:Case Reports in Radiology
Article Type:Case study
Date:Jan 1, 2016
Words:2705
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