PERFORATION OF THE ESOPHAGUS AFTER ESOPHA GEAL MANOMETRY

History and findings: A 75-year-old man was admitted for oesophageal m anometry because of dysphagia for the past 2 years and retrosternal bu rning sensation unrelated to exercise. His general condition was appro priate for his age. Investigations: An oesophagogram showed corkscrew- like deformation of a diffuse oesophageal spasm. The first, but incomp lete, manometry recorded clearly propulsive contractions with markedly raised and prolonged pressure, as in >>nutcracker oesophagus<<. The l ower oesophageal sphincter could not be demonstrated initially. Subseq uent pH measurements provided no evidence for increased gastrooesophag eal reflux. Treatment and further course: After the first manometry co nservative treatment was initiated with molsidomine, nifedipine and ni trospray sublingual, but the dysphagia was not significantly improved. A second manometry was performed before a planned surgical exploratio n. Placing of the catheter was again difficult and mild resistance exp erienced. Endoscopy revealed only minimal, presumably superficial, muc osal lesions. 2 days later bilateral pleural effusions together with m ediastinitis occurred. Conservative treatment was continued until fina lly a distal oesophageal perforation was demonstrated. At surgery the perforation was seen and a oesophagectomy with gastric pull-through an d intrathoracic anastomosis performed. However, the patient died of se ptic multiorgan failure. Conclusions: Oesophageal manometry is a safe but invasive method with few complications for measuring oesophageal m otility. Although this has not previously been reported, oesophageal p erforation with mediastinitis may end fatally, if the particular circu mstances are unfavourable. In addition to special anatomical features, type and state of the manometric catheter may present a risk factor.