Case Report: Acute complete esophageal obstruction associated with intraesophageal coagulation of RuiNeng enteral...

Enteral nutrition is widely used in critically ill patients and in patients with dysphagia. However, mechanical obstruction associated with coagulation of an enteral formula within the esophagus is extremely rare and may be easily mistaken for ordinary reflux, aspiration, or tube blockage. We report the case of a 69-year-old man with chronic obstructive pulmonary disease (COPD) who received nasogastric tube feeding with RuiNeng enteral nutrition formula, a high-protein, fiber-containing formula, because of impaired consciousness and critical illness. During tube feeding, the patient developed regurgitation of medication, overflow of enteral formula from the oral cavity, marked resistance during aspiration and injection through the nasogastric tube, and withdrawal of a milky-white paste-like substance. Bedside gastroscopy revealed extensive retention of whitish solid coagulated material in the esophageal lumen, causing severe esophageal obstruction. Partial endoscopic removal and fragmentation of the coagulated material were performed, the remaining material was cautiously pushed into the stomach under direct endoscopic visualization, and a jejunal feeding tube was placed under direct endoscopic visualization. Based on the clinical course and published reports, this case was probably associated with suspected impaired opening of the esophagogastric junction, possible nasogastric tube malposition, migration, coiling, or ineffective passage into the stomach with subsequent retention of enteral formula in the esophagus, and coagulation of the high-protein formula in a locally acidic or low-motility environment. Because no objective pH measurement of esophageal contents or the coagulated material was available, these mechanisms should be interpreted as plausible hypotheses rather than directly proven findings. This case highlights that, in critically ill patients receiving high-protein or fiber-containing enteral formulas, abnormal reflux, sudden tube resistance, or milky-white paste-like aspirate should prompt immediate cessation of feeding, reassessment of tube position and esophageal patency, and early bedside endoscopic diagnosis and treatment when necessary.