S4409 Beyond the Scope: Esophageal Rupture After Polyethylene Glycol-Based Bowel Preparation for a Routine Colonoscopy

Introduction: Boerhaave syndrome is a rare and life-threatening result of forceful emesis. It most commonly arises in the context of excessive alcohol intake or gastrointestinal pathology. Its occurrence following polyethylene glycol-based bowel prep for colonoscopy is exceedingly rare. We report an unusual and severe case of esophageal rupture following a MiraLAX® -based bowel regimen in a patient scheduled for routine surveillance colonoscopy. Case Description/Methods: A 75-year-old woman with a history of breast cancer, osteoporosis on bisphosphonates, gastroesophageal reflux disease, constipation, and colon polyps was scheduled for surveillance colonoscopy. After completing a full-dose MiraLAX® prep, she developed persistent vomiting followed by acute chest pain and dyspnea. She was urgently admitted to a local hospital. Imaging revealed pneumomediastinum and bilateral pleural effusions. Repeat computed tomography chest confirmed a 2 cm distal esophageal tear with contrast extravasation. She underwent bilateral chest tube placement, endoscopic esophageal suturing, stent placement, and G-J tube insertion. She was transferred to our facility in septic shock, required prolonged intubation and was managed with IV antibiotics, bowel rest, and total parenteral nutrition. Initial endoscopy confirmed stent position. However, repeat imaging showed stent migration, a large esophageal defect with fistula. The stent was repositioned. She ultimately required esophagectomy, right lung decortication, and cervical esophagostomy. Patient remained on enteral feeds via J-tube for almost 12 months. One year later, she underwent upper gastrointestinal tract reconstruction with colon interposition and Roux-en-Y. Patient is currently recovering. Discussion: This case highlights a rare but catastrophic complication of polyethylene glycol-based bowel preparation. While vomiting is a recognized adverse effect, the development of Boerhaave syndrome in this context is virtually unreported. Pre-existing gastroesophageal reflux disease and bisphosphonate use were probable contributing factors impairing esophageal mucosal integrity. The patient’s clinical course was prolonged and complex. Clinicians should maintain a high index of suspicion for Boerhaave syndrome in patients presenting with severe symptoms after bowel prep, even in low-risk settings. Early recognition and multidisciplinary management are essential for improving outcomes.