Successful Multidisciplinary Management of Esophageal Perforation Complicated by Septic Shock: A Race Against Time

Introduction

Esophageal perforation, although infrequent, is a well-defined and severe clinical condition representing a surgical emergency due to the risk of mediastinitis, sepsis, and multi-organ failure. Iatrogenic perforations account for approximately 70% of esophageal perforation cases [1]. Most iatrogenic perforations are related to endoscopic interventions. Other causes include spontaneous perforation (15%), foreign body ingestion (8%), and trauma (5%) [2]. Early diagnosis is crucial for effective management because mortality increases with diagnostic delay. Mortality can increase up to 33% with delayed diagnosis and can reach 100% when diagnosis exceeds 24 h; therefore, a high index of clinical suspicion is required in all cases to reduce morbidity and mortality. Early intervention to control the perforation is the mainstay of treatment. Nevertheless, the timing of the intervention is debatable. We report the case of a patient with fragile mucosa of the esophagus who had an esophageal perforation complicated by septic shock and multiple loculated pleural effusions, who was treated conservatively at first to allow proper healing of the mucosa and better visualization during esophageal stenting.

Case Report

PATIENT INFORMATION:

The patient was 43-year-old Saudi man known to have uncontrolled diabetes mellitus type 2, paranoid schizophrenia, severe acute esophagitis, and recurrent non-biliary pancreatitis, thought to be related to binge alcohol drinking. His medications included insulin, empagliflozin 10 mg once daily, linagliptin 5 mg once daily, escitalopram 10 mg once daily, risperidone 4 mg once daily, and paliperidone 150 mg injection once monthly. He presented to our emergency department on November 8 at 10: 20 AM with a 4-day history of left-sided chest pain and epigastric pain associated with repeated vomiting after a recent endoscopy by the gastroenterology team due to dysphagia and severe reflux, which showed a longitudinal whitish ulceration (Figure 1). There was no cough, shortness of breath, fever, or change in bowel habits. He was initially admitted to the hospital’s general ward for antifungal treatment and hydration due to severe esophageal candidiasis.

PHYSICAL EXAMINATION ON ADMISSION:

The patient was conscious, alert, and oriented to time, place, and person, and was not in respiratory distress. His temperature was 36.8°C, pulse was 116 bpm, blood pressure was 112/65, respiratory rate was 17 bpm, and oxygen saturation was 98% on room air. Systemic examination was unremarkable apart from a guarding in the abdomen with generalized tenderness.

LABORATORY AND RADIOLOGICAL INVESTIGATIONS ON ADMISSION:

A complete blood count showed a white blood cell count of 19×103/uL, neutrophil count 17.4×103/uL, and lymphocyte count 1.5×103/uL, with normal coagulation profile and procalcitonin 0.03 ng/ml. Renal and liver functions were normal. He was administered sodium 127 mmol/L, serum glucose 17 mmol, potassium 4.3 mmol/L, LDH 176 U/L, and lactic acid 2.42 mmol/L. Venous blood gas analysis showed pH 7.34, pCO2 25.9 mmHg, pO2 30, and HCO3 21 mmol/L. Serum blood ketones were 2.6 mmol/L. Results of laboratory tests are summarized in Table 1.

HOSPITAL COURSE AND MANAGEMENT:

The patient was initially admitted to the ward under care of the gastroenterology team. Shortly after transfer to the ward, the rapid response team was activated due to increased work of breathing, hypertension, tachycardia, and desaturation. The patient was subsequently transferred to the intensive care unit (ICU). An urgent chest X-ray (Figure 2) revealed bilateral tension pneumothorax, pleural effusions, and pneumomediastinum. The general surgery team was consulted, and bilateral chest tubes were inserted.

The patient was intubated and placed on mechanical ventilation and started on norepinephrine infusion for septic shock. Analysis of turbid pleural fluid showed a high amylase level, and a contrast-enhanced CT of the chest and abdomen confirmed a perforated esophagus (Figure 3). The diagnosis was based on the overall clinical picture, including the recent endoscopic history, chest radiography, contrast-enhanced CT findings, and the markedly elevated pleural fluid amylase, rather than being based on a single CT image alone. The gastroenterology team recommended conservative management, as esophageal stenting was deemed high-risk due to severe esophageal ulceration. A repeat diagnostic endoscopy and primary surgical repair were not selected initially because the patient had already experienced several days of symptoms, was in septic shock with bilateral pleural contamination, and had markedly ulcerated, friable esophageal tissue, making immediate definitive intervention high-risk. He was resuscitated with intravenous fluid boluses and broad-spectrum antimicrobials in the form of Tazocin, metronidazole, linezolid, and anidulafungin, in addition to a short course of amikacin as advised by the infectious disease consultant. A thoracic surgeon performed an urgent video-assisted thoracotomy with irrigation. On hospital day 2, a multidisciplinary meeting – including thoracic surgery, gastroenterology, internal medicine director, ICU consultants and head nurse, together with the patient’s family – determined that conservative management would continue. A repeat CT was planned after 1 week to reassess; if the leak persisted, esophageal stenting would be considered. Total parenteral nutrition was started immediately after stabilization and continued throughout the course of treatment. A follow-up CT with oral and intravenous contrast performed 10 days later confirmed persistent contrast leakage. The thoracic surgery team conducted a right-sided decortication due to ongoing empyema, and the patient was referred to King Fahad University Hospital for esophageal stenting and a second opinion. At King Fahad University Hospital in Al-Khobar, on November 21, the gastroenterology team successfully placed a 10-cm fully covered non-degradable esophageal stent (20-mm diameter) across the esophageal stricture, adequately spanning and sealing the leak site, which extended from 25 cm to 32 cm from the incisors. A follow-up contrast CT 1 week after the stent showed no further esophageal leakage (Figure 4).

All sepsis markers returned to normal and the patient was kept on mechanical ventilation with low settings and minimal fraction of inspired oxygen. Efforts to wean him off mechanical ventilation were unsuccessful due to severe respiratory muscle weakness, necessitating re-intubation. On hospital day 20, a tracheostomy was successfully performed, and extended tracheostomy collar weaning trials were initiated until he was successfully weaned from mechanical ventilation and discharged to the ward. The patient’s family was actively involved in all stages of his care and management. The tracheostomy tube was decannulated after 2 weeks and the patient was discharged home. The overall hospital stay was 5 weeks. At post-discharge follow-up, the stent was removed on December 24, and the patient remained clinically well without need for further intervention.

Discussion

This case shows the significant clinical challenges associated with esophageal perforation in a high-risk patient with multiple comorbidities. Our patient presented with several life-threatening complications, including bilateral tension pneumothorax, septic shock, mediastinitis, and respiratory failure, following an iatrogenic esophageal injury during diagnostic endoscopy. Despite the severity of presentation, a favorable outcome was achieved through a staged, multidisciplinary approach that emphasized early stabilization and infection control before definitive repair.

Although the patient was young and physically robust, factors such as uncontrolled diabetes mellitus, active smoking, alcohol use, and severe esophagitis substantially increased his risk of complications. The decision to defer immediate esophageal stenting was based on the gastroenterology team’s assessment that the markedly inflamed and ulcerated mucosa would not tolerate early intervention. In retrospect, this judgment proved critical to the success of subsequent definitive management. Although primary surgical repair is commonly considered standard treatment for esophageal perforation, it was not initially performed in this case because delayed presentation, septic shock, bilateral pleural contamination, and severe mucosal friability made immediate repair or early luminal intervention less likely to succeed. The diagnosis was established within approximately 8 h of hospital presentation, consistent with evidence showing that early recognition is the most important determinant of outcome. Mortality rates rise sharply when diagnosis is delayed beyond 24 h, with reported rates exceeding 50% in late presentations [1,2]. Prompt imaging and early drainage likely contributed to containment of mediastinal contamination in this case.

Imaging findings were typical of esophageal perforation, and the presence of elevated amylase levels in pleural fluid confirmed the esophageal origin of contamination [3]. Despite a prolonged hospital stay exceeding 3 weeks – common in cases complicated by empyema, prolonged ventilation, and repeated interventions – the patient ultimately achieved complete recovery [4]. The cornerstone principles of management include control of contamination, adequate drainage, source control, and nutritional support. In our patient, bilateral chest tube insertion followed by video-assisted thoracoscopic surgery and later decortication were essential in controlling infection. Minimally invasive approaches such as VATS offer effective source control while minimizing surgical morbidity [7].

The timing of definitive esophageal repair remains individualized. Conservative management is appropriate in carefully selected patients with contained perforations and adequate drainage [8]. In this case, delaying esophageal stenting until local inflammation had subsided allowed successful closure without complications. While esophageal stents are increasingly used, they are associated with risks such as migration and incomplete sealing, particularly in inflamed or friable tissue [9]. Delayed intervention after stabilization can improve outcomes in selected high-risk patients [10]. This case underscores the importance of multidisciplinary collaboration and clinical judgment. Rather than rigid adherence to early aggressive intervention, a patient-centered, staged approach allowed tissue recovery and optimized conditions for successful stent placement.

Conclusions

Esophageal perforation is rarely encountered in clinical practice, but it creates an urgent need for quick identification and specific therapy. This case demonstrates how patients with multiple comorbidities and fragile esophageal mucosa need immediate diagnosis and coordinated care from multiple specialists. Our patient achieved success through an initial conservative treatment plan that controlled infection and drainage and provided nutritional support before undergoing stent placement.

The patient required immediate surgical assistance and continuous surveillance to reduce additional complication. This case supports the view that in selected high-risk or immunocompromised patients, conservative management followed by delayed intervention can achieve better outcomes. Further research is warranted to refine treatment protocols and identify which patients benefit most from this staged approach.