A 58-year-old man with a 15-year history of alcohol use disorder presents to the emergency department with hematemesis and melena. On examination, he is hypotensive (BP 88/54 mmHg), tachycardic (HR 118/min), and has clinical signs of portal hypertension including spider angiomas, palmar erythema, and ascites. Upper endoscopy reveals large esophageal varices with active bleeding and stigmata of recent hemorrhage. After resuscitation and blood transfusion, he receives variceal ligation. On day 3 post-procedure, he develops sudden onset of severe chest pain, dysphagia, and subcutaneous emphysema. Chest X-ray shows pneumomediastinum. What is the most likely diagnosis?

Explanation

## Clinical Presentation and Diagnosis **Key Point:** Esophageal perforation is a rare but serious complication of endoscopic variceal ligation (EVL), occurring in 0.3–2% of procedures. The classic triad is pneumomediastinum, subcutaneous emphysema, and chest pain within 24–72 hours post-procedure. ### Mechanism of Injury EVL involves placement of elastic bands around varices, which causes tissue necrosis and eventual variceal obliteration. Overly aggressive banding, excessive traction, or perforation of the esophageal wall during band deployment can lead to transmural injury and perforation. ### Clinical Features in This Case - **Timing:** Day 3 post-EVL (classic window for delayed perforation) - **Symptoms:** Severe chest pain, dysphagia (esophageal origin) - **Physical findings:** Subcutaneous emphysema (air tracking into subcutaneous tissues) - **Imaging:** Pneumomediastinum on CXR (pathognomonic) ### Differential Considerations | Feature | EVL Perforation | Spontaneous Perforation | ACS | |---------|-----------------|------------------------|-----| | **Timing** | 24–72 hrs post-procedure | Sudden, no procedure | Acute | | **Subcutaneous emphysema** | Present | May be present | Absent | | **Dysphagia** | Prominent | Prominent | Absent | | **Pneumomediastinum** | Yes | Yes | No | | **Troponin elevation** | Possible (secondary) | No | Yes | **High-Yield:** Pneumomediastinum + subcutaneous emphysema + recent endoscopy = esophageal perforation until proven otherwise. ### Management 1. **Immediate:** NPO, broad-spectrum antibiotics, fluid resuscitation 2. **Definitive:** Surgical consultation for esophageal repair or drainage (depends on timing and contamination) 3. **Prognosis:** Mortality increases significantly if diagnosis delayed >24 hours **Clinical Pearl:** In cirrhotic patients with variceal bleeding, always counsel on EVL complications. Perforation carries 10–40% mortality even with prompt intervention. [cite:Harrison 21e Ch 286]