Phlegmonous esophagitis
Acute phlegmonous esophagitis is a very rare form of esophagitis in which there is a diffuse bacterial infection within the submucosa of the esophagus .
Terminology
Usually there is co-infection of the stomach (phlegmonous gastritis), and if both the stomach and esophagus are involved it is called phlegmonous oesophagogastritis . If other parts of the bowel are involved then phlegmonous enterocolitis can be seen.
Epidemiology
Acute phlegmonous esophagitis is exceedingly rare, a literature review in 2014 found only 12 reported cases . In this small cohort were ten male and two female patients. A third of the patients were poorly-controlled diabetics.
Risk factors
Although rare, some constant risk factors have been found :
- old age
- diabetes mellitus
- alcoholism
- malnutrition
- immunosuppression
Clinical presentation
Severe pain in the neck, midline chest and epigastrium (i.e. in the line of the esophagus) is the main presenting complaint. Breathlessness has also been experienced is some cases.
Pathology
The responsible organism for acute phlegmonous esophagitis varies in the literature, most commonly it has found to be Klebsiella pneumoniae.
Radiographic features
CT
- diffuse esophageal mural thickening
- esophageal intramural gas
- rim-enhancing foci of low density within the wall of the esophagus, likely representing intraesophageal abscesses
- concurrent pleural effusions are common
- other findings seen have included ulceration, strictures and a "pseudolumen".
Differential diagnosis
- dissecting intramural hematoma of the esophagus: high density wall thickening of the entire esophagus. Clinically presents as chest pain without evidence of infection.
- corrosive esophagitis: history of acid or base ingestion
- reflux esophagitis: often accompanied by a sliding esophageal hernia and mainly involves the mid to lower esophagus. No peripheral rim enhancement on the CT.
- diffuse esophageal spasm
- tubular duplication of the esophagus: usually asymptomatic.
Treatment and prognosis
Treatment is a mixture of intensive supportive care coupled with specific antimicrobial therapy, and providing timely surgical intervention if necessary.
Mortality rate of phlegmonous gastritis has been reported to be greater than 40%, but all 12 patients who had isolated phlegmonous esophagitis, survived, with appropriate intensive intervention .
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