Successful Multidisciplinary Management of Esophageal Perforation Complicated by Septic Shock: A Race Against Time

BACKGROUND Esophageal perforation is a life-threating condition caused by full-thickness disruption of the esophageal wall, leading to mediastinal and pleural contamination, with high mortality, especially when diagnosis or source control is delayed. CASE REPORT A 43-year-old man with uncontrolled type 2 diabetes mellitus, active smoking and alcohol use, paranoid schizophrenia, and severe acute esophagitis underwent diagnostic upper endoscopy for dysphagia. One week later, he presented with 4 days of left-sided chest pain, epigastric pain, and repeated vomiting. Shortly after admission he deteriorated, with hypoxemia and shock. Chest radiography showed bilateral tension pneumothoraces, pleural effusions, and pneumomediastinum. Bilateral tube thoracostomies were performed, and he required intubation, mechanical ventilation, and norepinephrine. Pleural fluid was turbid with markedly elevated amylase, and contrast-enhanced computed tomography (CT) confirmed esophageal perforation with mediastinal contamination. Because the mucosa was severely ulcerated and friable, immediate stenting was deferred. He was managed with broad-spectrum antimicrobials, drainage, video-assisted thoracoscopic irrigation, nil per os, total parenteral nutrition, and close radiologic follow-up. Persistent leakage prompted decortication and transfer for esophageal stenting. Follow-up imaging showed sealing of the leak, and he recovered completely. CONCLUSIONS Early recognition and timely intervention are essential. In selected high-risk patients, a staged multidisciplinary approach can lead to favorable outcomes.