Mount Sinai St. Luke's and Mount Sinai Roosevelt New York, NY
Award: Presidential Poster Award
Pavan K. Paka, MD1, Oluwasayo Adeyemo, MD, MPH2, Edward Lung, MD, MPH3, Priya K. Simoes, MD1; 1Mount Sinai St. Luke's and Mount Sinai Roosevelt, New York, NY; 2Mount Sinai Beth Israel Hospital, New York, NY; 3Mount Sinai Medical Center, New York, NY
Introduction: Food impactions are a common gastrointestinal emergency, occasionally requiring urgent retrieval of an obstructing food bolus from the esophagus. This is a case of food impaction in a large esophageal diverticulum that developed as a long-term complication of laparoscopic adjustable gastric banding (LAGB) for obesity.
Methods: A 76-year-old woman presented to the emergency room complaining of dysphagia and neck discomfort after eating turkey. Her medical history includes gastroesophageal reflux disease, heart failure and morbid obesity, treated with LAGB several years prior and subsequently removed four years prior to the current presentation. She had previous food impactions that resolved spontaneously without endoscopic intervention. On presentation she was anxious, uncomfortable-appearing, mildly hypoxic, but able to handle her oral secretions. Computed tomography (CT) imaging of the chest showed a dilated esophagus with a right lateral diverticulum containing an impacted 10cm x 7.4cm food bolus and lung opacities concerning for aspiration pneumonia. The patient underwent an endoscopy with partial removal of the massive food bolus that was lodged in the diverticulum. The GIF-190 and GIF- XP scopes could not be advanced into the true esophageal lumen due to compression of the lumen by the huge diverticulum. Three days later, an endoscopy was performed with removal of the remnant bolus from the esophageal diverticulum, and placement of an orogastric tube over a guidewire. The mucosa of the upper esophagus was noted to be dusky-appearing, likely from pressure necrosis. The patient had a month-long ICU stay for chronic hypoxic respiratory failure due to aspiration pneumonia and inability to wean off mechanical ventilation. Surgical intervention to repair the esophageal diverticulum was discussed, but was deferred given the patients age, morbid obesity and medical comorbidities. Ultimately a tracheostomy was placed for long-term mechanical ventilation and a gastrostomy tube was placed under fluoroscopic guidance for enteral nutrition. The patient was discharged to a long-term care facility. Discussion: This is a case of a large esophageal diverticulum that developed as a late complication of LAGB. Patients with prior LAGB presenting with dysphagia require imaging and possibly manometric evaluation to assess for pseudoachalasia. This directs need for endoscopic or surgical intervention to avoid progression to large esophageal diverticular disease and subsequent complications.
CT abdomen and pelvis with out contrast demonstrating an axial view of a large esophageal diverticulum with 10 cm food bolus.
CT abdomen and pelvis with out contrast demonstrating a coronal view of a large esophageal diverticulum and right sided aspiration pneumonia.
The upper third of the esophagus with dusky appearing mucosa in the large diverticulum seen during second endoscopy.
Disclosures: Pavan Paka indicated no relevant financial relationships. Oluwasayo Adeyemo indicated no relevant financial relationships. Edward Lung indicated no relevant financial relationships. Priya Simoes indicated no relevant financial relationships.