Gastrointestinal: oesophageal perforation during endoscopy for food impaction in eosinophilic oesophagitis

Oesophageal food impaction (OFI) is a common problem requiring urgent endoscopic therapy. It has an estimated annual incidence of 13 episodes per 100,000. Schatzki's ring and peptic stricture are the two most common causes. However, eosinophilic oesophagitis (EO) has not been well recognised as a potential aetiology until recently. One study found that EO was responsible for up to 50% of cases of OFI. While several studies have demonstrated the safety of both push and extraction techniques in the management of OFI, no studies have specifically looked at the different methods in patients with EO. Oesophageal perforation is perceived to be rare in this condition, however, it has been reported during routine endoscopy, oesophageal dilatation, and rigid oesophagoscopy. Although EO is generally thought of as a mucosal disease, full thickness oesophageal inflammation has been reported. Optimal treatment and management for EO remains uncertain due to lack of established evidence. Swallowed topical corticosteroids are widely used although its role as maintenance therapy is uncertain. Potential future treatment includes dietary therapy and novel monoclonal antibodies. Here, we report a case of perforation in OFI due to EO managed with the push technique and we urge caution with the use of this method. A 34 year-old female presented with suspected OFI after consuming meat. Twelve months previously an episode of OFI had required endoscopic removal of a bolus which was uneventful. She had no reflux symptoms and was not on any medications. At endoscopy on the following morning, a food bolus was found at the gastro-oesophageal junction and gentle pressure was applied with the aim of pushing the bolus through to the stomach (the push technique). A linear mucosal split with a perforation at the distal apex was identified. The bolus was removed in a piecemeal fashion with a polypectomy snare and three Resolution clips were applied to the defect. Chest pain was noted immediately following the procedure. The patient was fasted, administered intravenous antibiotics and a nasogastric tube inserted. A gastrograffin swallow was performed that revealed a persistent leak in the lower oesophagus (Figure 1, arrow). Urgent surgery, with a distal oesophagectomy, a proximal oesophageal stoma and a feeding jejunostomy was performed. The patient recovered and a reconstructive surgery using a retrosternal gastric tube was performed 3 weeks later. The resected oesophagus showed full thickness oesophageal inflammation with large numbers of eosinophils (Figure 2).