Acute phlegmonous esophagitis

Acute phlegmonous oesophagitis is a very rare disorder in which there is a diffuse bacterial infection within the submucosa and smooth muscle of the oesophagus ¹. It has a high mortality rate. Risk factors include old age, diabetes mellitus, alcoholism, malnutrition, and immunosuppression are well known predisposing factors ².

Usually there is co-infection of the stomach (phlegmonous gastritis), and if both the stomach and oesophagus are involved it is called phlegmonous oesophagogastritis ⁴.

Epidemiology

Acute phlegmonous oesophagitis is exceedingly rare, a literature review in 2014 found only 12 reported cases ¹. In this small cohort were ten male and two female patients. A third of the patients were poorly-controlled diabetics.

Clinical presentation

Severe pain in the neck, midline chest and epigastrium (i.e. in the line of the oesophagus) is the main presenting complaint. Breathlessness has also been experienced is some cases.

Pathology

The responsible organism for acute phlegmonous oesophagitis varies in the literature, most commonly it has found to be Klebsiella pneumoniapneumoniae.

Radiographic features

CT

• diffuse oesophageal mural thickening
• oesophageal intramural gas ³
• rim-enhancing foci of low density within the wall of the oesophagus, likely representing intraoesophageal abscesses
• concurrent pleural effusions are common
• other findings seen have included ulceration, strictures and a "pseudolumen".

Differential diagnosis

• Dissectingdissecting intramural haematoma: high attenuation wall thickening of the entire oesophagus. Clinically presents byas chest pain without symptomsevidence of infection.
• Corrosivecorrosive oesophagitis:  historyhistory of acid or base ingestion.
• Refluxreflux oesophagitis: oftenoften accompanied by a sliding esophageal hernia and mainly involves the mid to lower oesophagus. No peripheral rim enhancement on the CT.
• Diffusediffuse oesophageal spasm.
• Tubulartubular duplication of the oesophagus: asymptomatic 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 oesophagitis, survived, with appropriate intensive intervention¹.