Jonathan Pinto, MD, MPH, Ammar Asif, MD, Kafi Thomas, MD, Joan Culpepper-Morgan, MD, FACG
Harlem Hospital Center, New York, NY
Introduction: Mega-esophagus, usually due to achalasia or pseudoachalasia, can cause bronchial compression when filled with phytobezoars. We present a case of mega-esophagus not due to achalasia but with profound ventilatory consequences.
Case Description/Methods: A 67 year old alcoholic man presented with 24 hours of increasing dyspnea at rest. He denied fevers, chills, cough, chest pain, heartburn, dysphagia, abdominal pain or weight loss. On physical exam he was somnolent but arousable. He was able to speak in full sentences. Lungs revealed right sided rhonchi. He was afebrile, BP 211/100, pulse 68, respiratory rate 18, and O2 saturation 80-85% on room air which improved to 94% after 4L nasal O2. Urine toxicology was positive for opiates and cocaine. Chest CT showed a 6.8 cm esophagus filled with debris. It was herniated into the right upper thorax and terminated in a narrow taper at the aortic arch. The trachea deviated rightward and narrowed to 4 mm. The proximal left main-stem bronchus was narrowed to 2 mm. The right upper lobe showed scarring, cystic bronchiectasis, and pleural thickening. On day 2 the patient developed severe dyspnea and orthopnea. O2 saturation varied with position. After intubation and transfer to the ICU for treatment of acute ventilator failure, GI was consulted to decompress the mega-esophagus presumed due to end stage achalasia. EGD initially revealed a dilated esophagus with a phytobezoar. Upon partial clearing two lumens were noted: one containing more food and one which lead to a normal distal esophagus, stomach, and duodenum. The first opening was a large diverticulum located about 20cm from the incisors and was filled with recently ingested food. Transfer to a tertiary care center was recommended to manage possible total airway collapse. There, repeat chest CT showed a distended esophagus to the level of the aortic arch with no compression of the airways. Esophagram was not consistent with achalasia but demonstrated a large bezoar filled diverticulum. Repeat EGD was done to complete bezoar removal. Patient’s respiratory status normalized. Elective esophagectomy was planned, but the patient was lost to follow up.
Discussion: Our patient likely had a traction diverticulum as he gave no antecedent history of heartburn or dysphagia and the food in the bezoar was not fermented. In addition, his distal esophagus appeared normal on barium swallow. This is may be the first reported case of airway compression due to mega-esophagus due to a traction diverticulum.
Citation: Jonathan Pinto, MD, MPH, Ammar Asif, MD, Kafi Thomas, MD, Joan Culpepper-Morgan, MD, FACG. P0319 - AN UNUSUAL CASE OF VENTILATORY COMPROMISE AND MEGA-ESOPHAGUS. Program No. P0319. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.