Giselle Krebs, DO1, Pranav Patel, MD1, Harshit S. Khara, MD2 1Geisinger Health System, Danville, PA; 2Geisinger Health System, Danville, NJ Introduction: Gastroparesis is a form of autonomic neuropathy seen in patients with long-standing diabetes mellitus (DM). Gastroparesis causing refractory vomiting can increase the risk of esophageal perforation. We are presenting a case of refractory diabetic gastroparesis causing Boerhaave syndrome and mediastinal abscess which was successfully treated with endoscopic drainage using EUS-guided Axios stent.
Case Description/
Methods: The patient is a 30-year-old female with past medical history significant for type 1 DM causing frequent episodes of diabetic ketoacidosis (DKA), severe gastroparesis, and refractory vomiting. The patient presented due to sudden onset of chest pain, signs of sepsis, and DKA. CT demonstrated distal esophageal rupture and pneumomediastinum. Emergent EGD with placement of esophageal stent was performed and required broad spectrum antibiotics. Post procedure esophagogram did not demonstrate an esophageal leak. The patient was discharged on a mechanical soft diet in stable condition. Two weeks later, the patient returned with nausea, vomiting, and abdominal pain. CT demonstrated migration of the previously placed stent into the stomach and 5x7cm large mediastinal abscess. The patient underwent EGD and EUS with 8mm Axios stent placement with cyst esophagostomy and mediastinal abscess drainage (Image 1,2,3). This procedure was successful with subsequent drainage of the abscess through the esophagus. The patient continued to receive broad spectrum antibiotics and the Axios stent was removed two weeks later. Repeat CT imaging demonstrated resolution of the abscess. Discussion: Intractable vomiting causing Boerhaave syndrome is a medical emergency which can cause mediastinitis and the formation of mediastinal abscess. With advances in endoscopy techniques, EUS guided endoscopic drainage using Axios stent can offer a less invasive approach compared to cardiothoracic surgery or percutaneous drainage. Delayed complications such as esophageal stenosis, Axios stent blockage, and stent migration are possible, which necessitate prudent follow-up and close monitoring.
Figure: Image 1: Mediastinal abscess adjacent to lower esophagus and migrated esophageal stent in stomach Image 2: Status post Axios drainage of mediastinal abscess
Figure: Image 3: Endoscopic Axios stent drainage of mediastinal abscess
Disclosures: Giselle Krebs indicated no relevant financial relationships. Pranav Patel indicated no relevant financial relationships. Harshit Khara indicated no relevant financial relationships.
Giselle Krebs, DO1, Pranav Patel, MD1, Harshit S. Khara, MD2. P2915 - EUS-Guided Endoscopic Drainage of Mediastinal Abscess in Esophageal Rupture Secondary to Diabetic Gastroparesis, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
