A 54-year-old man presented to the ER with
chest pain. He underwent an upper endoscopy revealing a large linear esophageal tear and a CT chest showed free air in the mediastinum. He was managed conservatively and was discharged 2 days later. An UGI series revealed a distal
esophageal stricture. He was commenced on
esomeprazole for
gastroesophageal reflux symptoms and his
dysphagia improved significantly. Upper endoscopy revealed multiple rings throughout the esophagus. Biopsies from the distal and mid-esophagus were normal. The underlying pathophysiology, in patients with
dysphagia and a ringed esophagus has evoked debate in the literature. Opinions range from underlying
gastroesophageal reflux disease (
GERD) to
eosinophilic esophagitis (EE). Our patient's symptoms of
GERD and
dysphagia resolved with
proton pump inhibitor therapy. Normal histology excluded underlying EE. There have been a few case reports of
esophageal perforation in patients with a ringed esophagus, and underlying EE, but none with
spontaneous perforation occurring in a 'ringed esophagus'. Perforations in the upper and mid-esophagus can usually be managed conservatively, while those in the distal esophagus often need surgery due to the high risk of developing
mediastinitis. However, our patient, despite sustaining a large tear in the distal esophagus, did well with
conservative management. This case demonstrates that
spontaneous perforation in the ringed esophagus, with normal underlying histology can occur in the distal esophagus and may not require surgery.