Endoscopic closure of esophageal perforation in variceal hemorrhage

Endoscopy has emerged as a safe and effective treatment for esophageal perforation, but varices have traditionally been considered a contraindication. We aimed to treat an esophageal perforation with endoluminal suturing during an active variceal bleed.

A 55-year-old woman with (previously) compensated alcohol-associated cirrhosis presented with hematemesis, hypotension, and tachycardia. Although endoscopy was being arranged, the care team attempted to place a Sengstaken-Blakemore tube. The gastric balloon was inadvertently inflated in the esophagus; malposition was confirmed on chest radiograph. Bedside EGD revealed esophageal varices and a briskly bleeding, large, linear perforation extending from 24 to 36 cm from the incisors. Repeat CT was consistent with hemopneumomediastinum. She was brought to the interventional endoscopy suite, where an over-the-scope endoscopic suturing device was used both to close the perforation and to achieve hemostasis. No esophageal stent was placed. The esophagus was filled with water-soluble contrast, and a CT scan revealed no extraluminal contrast.

The patient was weaned off vasopressors and extubated. Her diet was advanced, and she had no residual dysphagia.

Endoscopic suturing may be considered as salvage therapy for esophageal perforation in selected patients who are not candidates for surgery.