S4379 EUS-Guided Endoscopic Drainage of Mediastinal Abscess in Esophageal Rupture Secondary to Diabetic Gastroparesis

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 endoscopic ultrasound (EUS)-guided Axios stent. Case Description/Methods: The patient is a 30-year-old woman with past medical history significant for type 1 diabetes mellitus causing frequent episodes of diabetic ketoacidosis, severe gastroparesis, and refractory vomiting. The patient presented due to sudden onset of chest pain, signs of sepsis, and diabetic ketoacidosis. Computed tomography (CT) demonstrated distal esophageal rupture and pneumomediastinum. Emergent esophagogastroduodenoscopy 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 5 × 7 cm large mediastinal abscess. The patient underwent esophagogastroduodenoscopy and EUS with 8 mm Axios stent placement with cyst esophagostomy and mediastinal abscess drainage. 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.