Case Snippets
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Correspondence to: Dr. Sathe, A/7, Jeevan Sudha Society, C D Barfiwala Road, Andheri (West), Mumbai 400 058. E-mail:
[email protected] Received September 17, 2005. Accepted November 20, 2005
Spontaneous esophageal perforation in a patient with achalasia cardia and rheumatoid arthritis Vaibhav S Banait, Veerendra Sandur, Murugesh M,
Ramesh V S, Jasmina Sawak, A K Gwalani ,*
Anjali D Amarapurkar,** Shobna J Bhatia
Departments of Gastroenterology, *Surgery and **Pathology, T N Medical College and B Y L Nair Ch. Hospital, Mumbai 400 008
Perforation of stasis ulcers in achalasia cardia has not been reported in literature. We report a 45-year old lady with achalasia and rheumatoid arthritis who developed perforation and esophago-mediastinal si nus at the site of stasis ulcers. She succumbed to respiratory infection after resection of the sinus tract, Heller’s cardiomyotomy, cervical esophagostomy and feeding jejunostomy. [Indian J Gastroenterol 2006;25:160-161]
P
erforations that are reported with achalasia cardia are generally iatrogenic, following balloon dilation of the lower esophageal sphincter (LES), or because of associated malignancy. Esophageal perforation in absence of malignancy or dilation in achalasia is seldom reported. 1 A 45-year-old housewife presented with intermittent non-progressive dysphagia for both solids and liquids, and intermittent bland regurgitation, since one year. There was no sensitivity to hot or cold food, or relief with vari ous maneuvers. There was no history of respiratory symp toms, chest pain, anorexia, or weight loss, or previous history suggestive of gastroesophageal reflux disease. The patient was diagnosed to have rheumatoid arthritis 4 years back, when she was detected to have peripheral symmetrical arthritis with characteristic deformities of metacarpophalangeal and proximal interphalangeal joints
Fig: Mucosa of lower esophagus showing 2-cm ulcer with ragged edges and normal surrounding mucosa
and positive rheumatoid arthritis factor. As she had no pain, she did not receive any medication. The patient was also diagnosed to have hypertension 5 years back, which was well controlled with atenolol 50 mg/day. Barium study showed non-peristaltic dilated esopha gus with air-fluid level, terminating in a tapered point. Upper gastrointestinal endoscopy revealed dilated esopha gus, with puckered closed LES through which the endo scope passed with gentle pressure. The lower esophagus showed a 2-cm ulcer with ragged edges (Fig), approxi mately 4 cm proximal to the gastroesophageal junction. There was no diverticulum. The fundus of the stomach was normal. Multiple esophageal biopsies from the ulcer edges were reported as nonspecific esophagitis, without evidence of malignancy, tuberculosis or cytomegalovirus infection. Tissue PCR (Real time PCR; Artus, Carpett Research, Germany) for tuberculosis bacilli, serologic ex amination for cytomegalovirus infection (DPC; Immulite 2000, USA) and ELISA for human immunodeficiency vi rus were negative. CT scan of the thorax and abdomen was normal except for presence of dilated esophagus. Esophageal manometry showed aperistaltic esophagus, baseline LES pressure 20 mmHg (normal 11-30) and in complete relaxation of the LES (residual pressure 11.6 mmHg, normal
