Can the patient with a recent OGD perforation and current CTAP findings be discharged?

Management of Patient with Recent OGD Perforation

Based on the current CT findings showing no evidence of pneumoperitoneum and clinical improvement, this patient can be safely discharged with appropriate follow-up instructions.

Assessment of Current Status

The patient had an esophagogastroduodenoscopy (OGD) perforation 2 weeks ago and has now undergone a follow-up CT of the abdomen and pelvis. The key findings include:

• No evidence of pneumoperitoneum on current scan
• Prominent and fluid-filled pylorus and first/second part of duodenum (noted on previous scan as well)
• Possible duodenal diverticulum in D2/D3 segments
• Diffuse mesenteric congestion and haziness
• Mild ascites
• Left hip implant

Decision-Making Algorithm

1. Evaluate for signs of ongoing perforation

   • No pneumoperitoneum on CT (most important finding)
   • No evidence of free fluid collections suggesting contained leak
   • Mild ascites may be residual from prior perforation but is not concerning in absence of pneumoperitoneum

2. Assess clinical status

   • If patient is hemodynamically stable
   • If patient is tolerating oral intake
   • If patient has no signs of sepsis (fever, tachycardia, hypotension)
   • If pain is well-controlled

3. Consider patient's comorbidities

   • History of T4 paraesophageal hernia repair with mesh increases risk of complications
   • However, current imaging shows resolution of the perforation

Rationale for Discharge

The World Society of Emergency Surgery (WSES) guidelines on blunt and penetrating bowel injury support that patients without evidence of transmural necrosis of digestive organs should undergo non-operative management 1. While this guideline specifically addresses traumatic injuries, the principle applies to iatrogenic perforations that are healing.

The absence of pneumoperitoneum on CT is particularly reassuring. Studies in other contexts have demonstrated that patients with a negative CT scan (no pneumoperitoneum) can be safely discharged from emergency departments 1. The current CT findings suggest the perforation has sealed and is resolving appropriately.

Discharge Plan

1. Patient education

   • Explain that the perforation appears to be healing well
   • Provide clear instructions about warning signs that would necessitate return to hospital:
     • Severe abdominal pain
     • Fever
     • Vomiting
     • Inability to tolerate oral intake

2. Follow-up arrangements

   • Schedule outpatient follow-up within 1-2 weeks
   • Consider repeat imaging only if symptoms recur

3. Dietary recommendations

   • Progress diet as tolerated
   • Start with soft foods and advance as comfortable

Potential Complications to Monitor

The American Journal of Emergency Medicine highlights that esophageal perforation is associated with high morbidity and mortality if not properly managed 2. However, in this case, the patient is now 2 weeks post-perforation with resolution of pneumoperitoneum on imaging, suggesting successful healing.

Conclusion

The absence of pneumoperitoneum on CT scan, along with the 2-week interval since the perforation occurred, indicates that the perforation is resolving appropriately. While the patient has a history of paraesophageal hernia repair that could complicate recovery, the current imaging findings support safe discharge with appropriate follow-up.