A53-17 Twice Torn: Recurrent Boerhaave Syndrome Leading to Chronic Esophageal Perforation and Persistent Hydropneumothorax

Abstract Introduction Esophageal perforation remains a highly morbid and potentially fatal condition, especially in elderly patients with significant comorbidities. Specifically, chronic esophageal perforation is relatively uncommon as a complication of Boerhaave syndrome and management often requires a tailored, multidisciplinary approach. We present a case of a recurrent esophago-pleural fistula causing septic shock in a critically ill octogenarian who was successfully treated with advanced endoscopic intervention. Case An 83-year-old female with a complex history of Boerhaave syndrome, recurrent esophageal perforations, and multiple prior esophageal stent placements presented with worsening back pain and nausea. In the emergency department, she was found to have a right-sided hydropneumothorax from a suspected recurrence of esophageal perforation. Despite initial placement of a chest tube, repeat imaging showed an interval increase in the pneumothorax along with worsening respiratory status. A second chest tube was placed without significant re-expansion of the lung. Both chest tubes appeared to be draining enteric fluid. The patient subsequently developed septic shock with acute hypoxic respiratory failure, requiring vasopressor support and mechanical ventilation. Management and Outcome Upper endoscopy revealed a 3 cm esophago-pleural fistula in the distal esophagus. The perforation was large enough to directly visualize lung tissue with chronic appearing discoloration and fibrotic changes to the parenchyma. Despite dual chest tube placement, re-expansion of the lung was only able to be achieved with positive pressure through intubation and mechanical ventilation. The patient underwent successful placement of an esophageal stent across the fistula site. For nutritional support and gastric decompression, a PEG tube with a jejunal feeding tube extension was also placed. Conclusion This case highlights the importance of an aggressive multidisciplinary approach to severe cases of esophageal perforations, especially with respiratory compromise. Initial stabilization includes IVF resuscitation, broad spectrum antibiotics that cover both oral and enteric flora, NPO, and other hemodynamic and respiratory support as indicated. This abstract is funded by: None