Acute phlegmonous oesophagitis

Acute phlegmonous oesophagitis is a very rare form of oesophagitis in which there is a diffuse bacterial infection within the submucosa of the oesophagus ¹.

Terminology

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. If other parts of the bowel are involved then phlegmonous enterocolitis can be seen.

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.

Risk factors

Although rare, some constant risk factors have been found ²:

• 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 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 pneumoniae.

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

• dissecting intramural haematoma of the oesophagus: high density wall thickening of the entire oesophagus. Clinically presents as chest pain without evidence of infection.

• corrosive oesophagitis: history of acid or base ingestion

• reflux oesophagitis: often accompanied by a sliding oesophageal hernia and mainly involves the mid to lower oesophagus. No peripheral rim enhancement on the CT.

• diffuse oesophageal spasm

• tubular duplication of the oesophagus: 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 intervention ¹.