Gastrointestinal: A case of spontaneous rupture of esophageal diverticulum

Abstract

A 64-year-old man who had a history of rheumatoid arthritis and Sjogren’s syndrome presented with a 5-h history of acute severe left upper abdominal pain without history of trauma, surgery, and obvious vomit. His initial laboratory tests revealed high white blood cell count (14.5 × 103/μL), elevated percent of neutrophils (81.2%), high cardiac troponin T (0.103 μg/L), normal serum amylase, normal renal function tests, and normal liver function tests. His electrocardiogram and abdominal computed tomography scan were unremarkable. He was given empirical antibiotic therapy and analgesic therapy with flurbiprofen. The pain relieved gradually. However, 6 days later, he developed severe dyspnea, and evaluation revealed tachycardia (115/min), tachypnea (25/min), and hypoxia (saturation O2 91% with oxygen flow 3 L/min) but no hypotension (blood pressure 124/85 mmHg). On the same day, his white blood cell count increased to 16.7 × 103/μL. Repeat liver function test revealed low serum albumin (27.7 g/L). Chest computed tomography showed left-sided hydropneumothorax (Fig. 1). Closed drainage of thoracic cavity was performed, and food remains (tomatoes, lettuce, and noodles) could be seen in the drainage tube. Subsequent gastroscopy showed that there was a diverticulum (white arrows) of the esophagus 37–39 cm from the incisor teeth with a transluminal longitudinal tear (black arrows) in the left lateral wall (Fig. 2). Esophageal lumen was marked with red arrows. After fasting, closed drainage, antibiotic therapy, and nutritional support for 1 month, the patient underwent distal esophageal esophagectomy and partial gastrectomy. The patient was discharged in good clinical condition. Spontaneous rupture of esophageal diverticulum is a rare but important differential diagnosis of acute upper abdominal pain given mortality is very high without prompt intervention. This case report describes a spontaneous rupture of esophageal diverticulum diagnosed by drainage fluid contents and gastroscopy and treated successfully by surgical resection.