A delayed presentation of Boerhaave's syndrome with mediastinitis managed using the over-the-scope clip
A 69-year-old gentleman presented to hospital following an episode of forceful vomiting and chest discomfort. An initial chest radiograph revealed a left-sided pleural effusion. After several days with no improvement in the patient's condition, it was decided to perform a CT chest, which showed a suspected oesophageal perforation with mediastinitis. Two water-soluble contrast swallows were performed, which showed no leak and thus it was decided to continue to treat the patient conservatively.\nHowever, a subsequent contrast CT scan showed a persistence of the perforation with ongoing mediastinitis (Fig. ). In consideration of the size of the defect and the delay in presentation, it was decided not to perform surgery. An endoscopy revealed a persistent perforation at the lower oesophagus. This was closed successfully using the OTSC. This is demonstrated by a subsequent contrast swallow, showing no leak of contrast with the clip in place (Fig. ). A naso-jejunal tube was inserted at the same time to facilitate post-pyloric feeding. The patient was initially managed with total parenteral nutrition post procedure for 3 days before being fed via an NJ tube. Furthermore, the patient was treated with intravenous antibiotics and bilateral chest drains were inserted. These measures resulted in a successful closure of the defect and resolving mediastinitis. The patient was later discharged from hospital with no further complications. At 6-month follow up, he was clinically well apart from a left-sided small chronic empyema, which was drained.