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Conservative management of esophageal perforation
AJG – September, Suppl., 2001
was found have a left lower quadrant mass, 3 ⫻ 4 cm, not tender, and the stool tested positive for occult blood. Hypochromic microcytic anemia was documented. CT scan with contrast revealed left lower quadrant mass impinging on the left colon. Colonoscopy was then performed which revealed a polypoid mass at 15 cm from ano-rectal junction measuring 2 ⫻ 3 cm, with friable overlying mucosa, and narrow, intact attachment at the colonic mucosa. Multiple biopsies were obtained. Pathological examination revealed keratinizing squamous cell carcinoma. At surgery, the patient was found to have left ovarian dermoid cyst with squamous cell carcinoma invading the rectosigmoid. This is the first case of squamous cell carcinoma of an ovarian dermoid presenting as rectal mass.
618 A mullerian duct tumor presenting as a sessile polpoid colonic lesion William F. Erber, MD, FACG, Jonathan Erber, BA, Aliza Honarvar, MD. Division of Gastroenterology, Dept. of Medicine, Maimonides Medical Center, State University of New York, Health Sciences Center, Brooklyn, NY. This is a report of a case of poorly differentiated adenocarcinoma of mullerian duct origin which involved the colon. A 78 year old woman presented with diminished appetite, early satiety, epigastric abdominal pain, regurgitation with associated heartburn and episodes of rectal bleeding, without a change in bowel habits. The patient’s father had died of colon cancer. The physical exam was unremarkable. The stool was brown and guaiac positive. Routine lab studies revealed a hemoglobin of 11.9, a hematocrit of 38, an MCV of 84, and a normal differential. Aside from a cholesterol of 257, the chemistries including the LFT’s were all normal. Imaging studies were normal aside from cholelithiasis. Esophagogastroduodenoscopy was unremarkable. A colonoscopy revealed a diffusely spastic colon. At the proximal ascending colon, a larger than 6cm irregular, sessile lesion was encountered. The lesion was not ulcerated, and no active bleeding was seen. Biopsies showed a poorly differentiated adenocarcinoma. Immunohistochemistry proved this to be of mullerian duct origin. CA-125 and progesterone receptors were positive. An exploratory laparotomy revealed a bulky mass along the ascending colon that appeared to be arising from the retroperitoneum. The right ovary while appearing normal itself was fused to this mass. Bilateral oophorectomy and omentectomy was performed for staging and peritoneal fluid washings were obtained for cytology, both which were negative. The tumors were non-resectable and the colon was left in situ for treatment with postoperative chemotherapy. The patient did well following six courses of chemotherapy consisting of Taxol and Carboplatinum. The CA-125, which was elevated prior to the start of chemotherapy, returned to normal. A repeat-colonoscopy following the chemotherapy revealed no evidence of residual tumor involvement of the colon, and again was unremarkable two years later. A second look surgery also revealed no evidence of residual tumor. Lesions that mimic primary colonic tumors must be considered when performing colonoscopy. The successful outcome in the patient’s management is credited to careful scrutiny of biopsy specimens.
619 Conservative management of esophageal perforation Noel R Fajardo1, Ian Mark M Gampon2, Maria T Valdes3, Sunil K Dhuper3 and Mark A Korsten1*. 1Bronx Vamc, New York, NY; 2 Elmhurst MC, New York, NY; and 3North Central Bronx Hosp, Bronx, NY. Purpose: The standard of care in the management of esophageal perforation with evidence of mediastinitis is emergent surgical intervention. It is believed that a delay in surgery may lead to increased morbidity and mortality in this condition. However, with the availability of newer and more potent antibiotics, non-surgical approaches may be proposed.
Abstracts
S195
Methods: We present here a case report in which a patient received conservative, non-surgical management of an esophageal perforation complicated by mediastinitis. A 31 year old male who ingested a fish bone four days later presented with fever (38.3 C) and difficulty with swallowing. On admission, he was hemodynamically stable and was not in need of any ventilatory support. Initial laboratory was significant for leukocytosis (14,900, 80% neutrophils). Broad spectrum antibiotics were administered (ticarcillin/clavulanate) and he was referred to the GI Service. Upper endoscopy was performed, and a 4 cm. fish bone was found to be lodged in a pseudodiverticulum of the cervical esophagus. The fish bone was eventually extracted using a snare. A computed tomography with gastrograffin contrast was done, which showed mediastinitis without any evidence of contrast leak. Given the stable clinical picture of the patient, a decision was made to continue the conservative management, thus he was kept NPO and maintained on the parenteral antibiotics. Results: Over the course of the hospital stay, he continued to remain afebrile and asymptomatic. A gastrograffin esophagram was done on the fifth day after admission, which showed a patent esophagus still with no evidence of contrast leak. The patient was then started on a clear liquid diet, which was advanced as tolerated. After completing a 14-day course of antibiotics, he was discharged in a stable condition. Conclusions: We believe that the successful conservative management of this patient is instructive as he was spared unnecessary surgical intervention and possible post-operative morbidity. This approach may be a reasonable alternative in the management of esophageal perforation with evidence of mediastinitis if a patient is hemodynamically stable, is not acutely ill and appears to be responding to parenteral antibiotics.
620 Fatal E. coli brain abscesses following dilatation of a strictured colonic interposition in a patient with an esophageal metallic stent Joseph Fares, MD, Salim Al-Khatatneh, MD, Walid Baddoura, MD. Seton Hall University School of Graduate Medical Education, South Orange, NJ, St Joseph’s Regional Medical Center, Paterson, N.J. Introduction: CNS infections such as meningitis and brain abscesses are uncommon complications of esophageal dilatation or esophageal stenting. It is postulated that the pressure of the dilator causes microscopic esophageal perforations leading to bacterial extrusion into the mediastinum. These organisms then invade the surrounding vessels and may be carried to the brain via the vertebral vein system. Case report: This is a 41 year-old male with history of lye-induced esophageal stricture requiring partial esophagectomy with colonic interposition. Subsequently, the neoesophagus strictured down prompting frequent endoscopic dilatations. After a second episode of perforation resulting in a tracheoesophageal fistula, an esophageal metallic stent was placed. Few months later, a stricture developed distal to the stent necessitating repeated endoscopic balloon dilatations. Two weeks after the last procedure, he was hospitalized with left sided weakness and slurred speech. Brain CT scan revealed multiple ringenhancing lesions in the right basal ganglia and parietal lobe. MRI was not done due to the presence of the metallic stent. The possibility of infectious vs. metastatic disease was raised. In the absence of fever and leukocytosis, empiric therapy for toxoplasmosis was initiated in addition to IV steroids. HIV testing, toxoplasmosis serology, echocardiogram, and work-up for primary tumor were all negative. There was no clinical or radiographic improvement. On the evening prior to a scheduled brain biopsy, the patient suddenly became comatose secondary to brainstem herniation. He expired few days later. Autopsy showed multiple brain abscesses due to E. coli, which was also cultured from the necrotic tissue surrounding the esophageal stent. Conclusion: To our knowledge, this is the first such reported case. One can postulate that the etiology of the E. coli abscesses could be related to one or more of these predisposing factors: esophageal dilatations; metallic stent and/or colonic mucosa acting as a nidus for bacterial colonization.
was found have a left lower quadrant mass, 3 ⫻ 4 cm, not tender, and the stool tested positive for occult blood. Hypochromic microcytic anemia was documented. CT scan with contrast revealed left lower quadrant mass impinging on the left colon. Colonoscopy was then performed which revealed a polypoid mass at 15 cm from ano-rectal junction measuring 2 ⫻ 3 cm, with friable overlying mucosa, and narrow, intact attachment at the colonic mucosa. Multiple biopsies were obtained. Pathological examination revealed keratinizing squamous cell carcinoma. At surgery, the patient was found to have left ovarian dermoid cyst with squamous cell carcinoma invading the rectosigmoid. This is the first case of squamous cell carcinoma of an ovarian dermoid presenting as rectal mass.
618 A mullerian duct tumor presenting as a sessile polpoid colonic lesion William F. Erber, MD, FACG, Jonathan Erber, BA, Aliza Honarvar, MD. Division of Gastroenterology, Dept. of Medicine, Maimonides Medical Center, State University of New York, Health Sciences Center, Brooklyn, NY. This is a report of a case of poorly differentiated adenocarcinoma of mullerian duct origin which involved the colon. A 78 year old woman presented with diminished appetite, early satiety, epigastric abdominal pain, regurgitation with associated heartburn and episodes of rectal bleeding, without a change in bowel habits. The patient’s father had died of colon cancer. The physical exam was unremarkable. The stool was brown and guaiac positive. Routine lab studies revealed a hemoglobin of 11.9, a hematocrit of 38, an MCV of 84, and a normal differential. Aside from a cholesterol of 257, the chemistries including the LFT’s were all normal. Imaging studies were normal aside from cholelithiasis. Esophagogastroduodenoscopy was unremarkable. A colonoscopy revealed a diffusely spastic colon. At the proximal ascending colon, a larger than 6cm irregular, sessile lesion was encountered. The lesion was not ulcerated, and no active bleeding was seen. Biopsies showed a poorly differentiated adenocarcinoma. Immunohistochemistry proved this to be of mullerian duct origin. CA-125 and progesterone receptors were positive. An exploratory laparotomy revealed a bulky mass along the ascending colon that appeared to be arising from the retroperitoneum. The right ovary while appearing normal itself was fused to this mass. Bilateral oophorectomy and omentectomy was performed for staging and peritoneal fluid washings were obtained for cytology, both which were negative. The tumors were non-resectable and the colon was left in situ for treatment with postoperative chemotherapy. The patient did well following six courses of chemotherapy consisting of Taxol and Carboplatinum. The CA-125, which was elevated prior to the start of chemotherapy, returned to normal. A repeat-colonoscopy following the chemotherapy revealed no evidence of residual tumor involvement of the colon, and again was unremarkable two years later. A second look surgery also revealed no evidence of residual tumor. Lesions that mimic primary colonic tumors must be considered when performing colonoscopy. The successful outcome in the patient’s management is credited to careful scrutiny of biopsy specimens.
619 Conservative management of esophageal perforation Noel R Fajardo1, Ian Mark M Gampon2, Maria T Valdes3, Sunil K Dhuper3 and Mark A Korsten1*. 1Bronx Vamc, New York, NY; 2 Elmhurst MC, New York, NY; and 3North Central Bronx Hosp, Bronx, NY. Purpose: The standard of care in the management of esophageal perforation with evidence of mediastinitis is emergent surgical intervention. It is believed that a delay in surgery may lead to increased morbidity and mortality in this condition. However, with the availability of newer and more potent antibiotics, non-surgical approaches may be proposed.
Abstracts
S195
Methods: We present here a case report in which a patient received conservative, non-surgical management of an esophageal perforation complicated by mediastinitis. A 31 year old male who ingested a fish bone four days later presented with fever (38.3 C) and difficulty with swallowing. On admission, he was hemodynamically stable and was not in need of any ventilatory support. Initial laboratory was significant for leukocytosis (14,900, 80% neutrophils). Broad spectrum antibiotics were administered (ticarcillin/clavulanate) and he was referred to the GI Service. Upper endoscopy was performed, and a 4 cm. fish bone was found to be lodged in a pseudodiverticulum of the cervical esophagus. The fish bone was eventually extracted using a snare. A computed tomography with gastrograffin contrast was done, which showed mediastinitis without any evidence of contrast leak. Given the stable clinical picture of the patient, a decision was made to continue the conservative management, thus he was kept NPO and maintained on the parenteral antibiotics. Results: Over the course of the hospital stay, he continued to remain afebrile and asymptomatic. A gastrograffin esophagram was done on the fifth day after admission, which showed a patent esophagus still with no evidence of contrast leak. The patient was then started on a clear liquid diet, which was advanced as tolerated. After completing a 14-day course of antibiotics, he was discharged in a stable condition. Conclusions: We believe that the successful conservative management of this patient is instructive as he was spared unnecessary surgical intervention and possible post-operative morbidity. This approach may be a reasonable alternative in the management of esophageal perforation with evidence of mediastinitis if a patient is hemodynamically stable, is not acutely ill and appears to be responding to parenteral antibiotics.
620 Fatal E. coli brain abscesses following dilatation of a strictured colonic interposition in a patient with an esophageal metallic stent Joseph Fares, MD, Salim Al-Khatatneh, MD, Walid Baddoura, MD. Seton Hall University School of Graduate Medical Education, South Orange, NJ, St Joseph’s Regional Medical Center, Paterson, N.J. Introduction: CNS infections such as meningitis and brain abscesses are uncommon complications of esophageal dilatation or esophageal stenting. It is postulated that the pressure of the dilator causes microscopic esophageal perforations leading to bacterial extrusion into the mediastinum. These organisms then invade the surrounding vessels and may be carried to the brain via the vertebral vein system. Case report: This is a 41 year-old male with history of lye-induced esophageal stricture requiring partial esophagectomy with colonic interposition. Subsequently, the neoesophagus strictured down prompting frequent endoscopic dilatations. After a second episode of perforation resulting in a tracheoesophageal fistula, an esophageal metallic stent was placed. Few months later, a stricture developed distal to the stent necessitating repeated endoscopic balloon dilatations. Two weeks after the last procedure, he was hospitalized with left sided weakness and slurred speech. Brain CT scan revealed multiple ringenhancing lesions in the right basal ganglia and parietal lobe. MRI was not done due to the presence of the metallic stent. The possibility of infectious vs. metastatic disease was raised. In the absence of fever and leukocytosis, empiric therapy for toxoplasmosis was initiated in addition to IV steroids. HIV testing, toxoplasmosis serology, echocardiogram, and work-up for primary tumor were all negative. There was no clinical or radiographic improvement. On the evening prior to a scheduled brain biopsy, the patient suddenly became comatose secondary to brainstem herniation. He expired few days later. Autopsy showed multiple brain abscesses due to E. coli, which was also cultured from the necrotic tissue surrounding the esophageal stent. Conclusion: To our knowledge, this is the first such reported case. One can postulate that the etiology of the E. coli abscesses could be related to one or more of these predisposing factors: esophageal dilatations; metallic stent and/or colonic mucosa acting as a nidus for bacterial colonization.