1217 - Detection of Esophageal Perforation with Nontraditional VFSS Views in an Inpatient Rehabilitation Facility

Feeding intolerance due to esophageal perforation complicated by hydropneumothorax.

Case Description:

A 64 year-old man with peripheral vascular disease and type 2 diabetes was admitted to inpatient rehabilitation facility (IRF) for post-amputation care for a new left below-knee amputation. Three days post-admission on a regular diet, he developed a new globus sensation with associated vomiting and coughing. He was subsequently referred for a video fluoroscopic swallowing study (VFSS). 

The standard view VFSS demonstrated normal oropharyngeal function. However, when the view was directed inferiorly, there was concern for mid-esophageal outpouching. Furthermore, each bolus showed several episodes of bouncing across a prolonged transit through the middle and lower esophagus. 

Approximately 1 week after VFSS, the patient developed acute right-sided chest pain. Advanced imaging ultimately revealed a full-thickness, right lower esophageal wall defect with hydropneumothorax. The patient’s symptoms resolved with placement of an esophageal stent and an intercostal muscle flap repair.

Discussions:

In the IRF setting, VFSS is primarily used to assess oropharyngeal and esophageal swallow function, predominantly in patients with new neurologic impairments. In the current case, standard view VFSS, which typically only includes the upper esophagus, was functionally unremarkable. However, assessment of more inferior portions of the esophagus demonstrated a soft tissue defect which ultimately required surgical intervention. These findings highlight the application of nontraditional VFSS views in the IRF setting for assessing functional and structural feeding and swallowing impairments. 

Conclusions:

This case underscores the broader diagnostic utility of VFSS in the inpatient rehabilitation setting. VFSS should be considered in all IRF patients with new swallowing complaints. For patients without neurologic conditions that may lead to oropharyngeal or esophageal dysfunction, non-traditional VFSS views may provide critical diagnostic information.