Iatrogenic oesophageal perforation after pneumatic balloon dilatation for achalasia

Clinical History

An elderly male suffering from malaise, limited oral intake and weight loss since a few months, recently diagnosed with achalasia presented to our hospital. There were several comorbidities including atrial fibrillation, congestive heart failure, multifactorial anaemia, melaena from bleeding metaplastic gastric polyp, renal function impairment.
Worsening of epigastric pain shortly after pneumatic balloon dilatation (anticoagulation withdrawn before procedure).

Imaging Findings

After oesophagogastroduodenoscopy and upper digestive radiographic study (Fig.1) revealed abnormal oesophageal motility, manometry diagnosed achalasia with non-relaxing lower sphincter.
Following pneumatic balloon dilatation (Fig.2a), the patient complained of epigastric pain with radiographic (Fig.2b) appearance of pneumomediastinum and minimal pleural effusions suggesting oesophageal perforation.
To provide a consistent basis for therapeutic choice, multidetector CT-oesophagography (Fig.3) was performed using peroral opacification with diluted water-soluble iodinated contrast. CT depicted patent gastroesophageal lumen, and confirmed minimal bilateral pleural effusions plus moderate diffuse pneumomediastinum mostly located near the distal thoracic oesophagus. Additionally, the dorsal aspect of the distal thoracic oesophagus showed segmental asymmetric soft-tissue thickening consistent with intramural iatrogenic injury.
Without mediastinal fluid collections and extraluminal leakage of ingested contrast, surgeons opted for conservative treatment including parenteral nutrition, antibiotics and transfusions. The patient remained afebrile and haemodynamically stable. Before discharge, radiographic follow-up (Fig.4) showed decreasing pneumomediastinum, persistent minimal pleural effusions.

Discussion

Achalasia is a rare neurodegenerative oesophageal motility disorder, characterised by decreased peristalsis and impaired relaxation of the lower oesophageal sphincter (LOS), resulting from inflammatory damage to the visceral myoenteric plexus. Achalasia usually manifests in adulthood with dysphagia, regurgitation, chest pain and weight loss. Whereas oesophageal manometry is the gold standard diagnostic technique, endoscopy allows ruling out mechanical obstruction, particularly a malignant stricture. Normal barium esophagography findings do not rule out achalasia, and the classical “tapering” appearance of the distal oesophagus with aperistalsis and upstream dilatation represents chronic disease [1-4] .
Pneumatic balloon dilatation (PBD) is the first-line nonsurgical option to palliate achalasia by disrupting the LOS muscle fibers. Alternative treatments include open or laparoscopic Heller myotomy, and the recently introduced endoscopic oesophagomyotomy. PBD and surgery demonstrated similar efficacy (85-90% mid-term symptomatic relief) [1-3, 5].
Although repeated dilatation may be required, PBD is minimally invasive and generally well tolerated. The potentially serious complication represented by iatrogenic oesophageal perforation (IOP) occurs in 0.37%-4.3% of patients, is more frequent in elderly patients and associated with prolonged hospitalization and occasional mortality. IOP may be detected intraprocedurally or manifest hours or days later with pain, hypotension or fever [6, 7].
When plain radiographs are initially obtained, IOP may be heralded by mediastinal widening, pneumomediastinum, pleural effusion or hydropneumothorax. However, diagnostic delay may result from technically insufficient views, absent or subtle radiographic signs. Fluoroscopic contrast oesophagography (FCO) may confirm IOP with excellent specificity but moderate (~75%) sensitivity via demonstration of water-soluble contrast extravasation, but is cumbersome in critically ill patients. As this case exemplifies, multidetector CT-oesophagography (CT-O) represents the ideal “one-stop shop” technique to rapidly and comprehensively diagnose IOP. Signs include segmental oesophageal mural thickening, periesophageal air or fluid collections, pneumomediastinum, left-sided pleural effusion or hydropneumothorax. With injuries to the oesophago-gastric junction, extraluminal air may dissect inferiorly in the abdomen Mural discontinuity and contrast leakage into mediastinum or pleural space represents the most specific sign of full-thickness perforation. Since CT has 100% estimated sensitivity and negative predictive value, performing FCO is unnecessary after negative CT findings [8-11].
Management of IOP depends on severity: conservative treatment (nil per mouth, parenteral nutrition, intravenous antibiotics) is feasible provided that sepsis is absent, and CT excludes heavy contamination or contrast extravasation in mediastinum, pleural space, or peritoneum. Oesophageal stenting is an increasingly appealing option. Alternatively, surgical drainage, perforation repair and myotomy are required [6, 7, 12].

Differential Diagnosis List

Final Diagnosis

Iatrogenic esophageal perforation after balloon dilatation for achalasia. Conservative treatment.

URL:	https://www.eurorad.org/case/13193
DOI:	10.1594/EURORAD/CASE.13193
ISSN:	1563-4086