Abstract / Summary
Abstract Background Nasogastric tube (NGT) placement is frequently used for enteral access in critically ill patients. Esophageal perforation with intrapleural tube migration is rare but can cause major pleural contamination, infection, and respiratory complications. We report an unusual case of recurrent right-sided empyema associated with an NGT traversing a distal esophageal perforation into the right pleural cavity. Case presentation A 90-year-old woman with hypertension, diabetes mellitus, chronic kidney disease, previous cerebrovascular accident, severe neurological impairment, tracheostomy, and chronic mechanical ventilation was transferred from another healthcare facility on 11 October 2023 for management of recurrent right pleural empyema. The NGT had been inserted at the referring facility during September 2023; the available records did not document how its position was verified before use, whether insertion was difficult, or whether repeated attempts were required. On admission she had a Glasgow Coma Scale score of 6/15 but was hemodynamically stable. A right intercostal chest tube was draining purulent material, and the original case documentation noted drainage resembling enteral feed. Chest CT demonstrated the distal NGT within the right pleural space, with pleural effusion and gas bubbles, consistent with an esophago-pleural communication. Following multidisciplinary review, she underwent urgent esophageal repair and right lung decortication on 14 October 2023. Postoperatively she remained nil per os and received total parenteral nutrition and culture-directed antimicrobial therapy. A Gastrografin study on 22 October was inconclusive, and CT raised concern for possible postoperative contrast extravasation; pharyngo-esophagoscopy on 23 October demonstrated no active leak. Enteral feeding was then restarted and tolerated. At the last documented assessment on 31 October she remained hemodynamically stable and ventilator-dependent through her tracheostomy while tolerating enteral feeding. Conclusions Enteral-feed-like material in a pleural drain should prompt urgent evaluation for gastrointestinal–pleural communication and feeding-tube malposition. CT can define the abnormal tube course and associated thoracic complications. This case highlights the importance of reliable NGT position verification before use and prompt multidisciplinary source control when esophageal perforation is accompanied by pleural contamination.