Endoscopic rescue of critical esophageal perforation with septic shock in a patient with incidental massive upper gastrointestinal ascariasis: a case report

Background Esophageal perforation represents an uncommon yet life-threatening acute condition. When traditional open or repair surgeries are performed on patients with severe esophageal perforations that have a long course of illness, they are highly invasive and result in a high systemic inflammatory burden, leading to a significantly increased risk of postoperative infection and anastomotic leakage; many critically ill patients are unable to tolerate the physical toll of surgery. With continued advances in endoscopic diagnostic and therapeutic techniques, endoscopic minimally invasive interventions have become a potential treatment option for these high-risk patients. Reports on endoscopic management of severe esophageal perforation with extensive upper gastrointestinal ascariasis remain scarce. Individualized regimens including prolonged anthelmintic therapy are needed. Case presentation A 73-year-old male without pre-existing comorbidities was referred to our institution following a 7-day history of dysphagia. Upon admission, he presented with established septic shock necessitating mechanical ventilation and vasopressor therapy. Computed tomography revealed an impacted bony foreign body in the esophagus with signs of perforation and infection. Emergency endoscopic intervention was preferentially performed after multidisciplinary discussion and family informed consent. We successfully removed the impacted pig bone and confirmed a localized esophageal perforation; during endoscopic examination, we incidentally discovered a large number of live Ascaris worms in the stomach, duodenum, and proximal jejunum. The patient received comprehensive treatment, including enteral nutrition via a jejunal tube, empirical albendazole therapy extended to 3 days, and potent antimicrobial therapy. Follow-up gastroscopy and imaging studies indicated that the patient was recovering well. Conclusions This case suggests that esophageal foreign-body presenting merely with dysphagia can rapidly progress to esophageal perforation, and even respiratory failure and septic shock. Endoscopic foreign-body extraction can serve as an effective rescue therapeutic modality for patients with delayed presentation who have developed severe complications including perforation and critical infection; Severe ascariasis with extensive retrograde migration involving the stomach, duodenum, and proximal jejunum is rare, this case achieved a favorable outcome following individualized anthelmintic therapy and comprehensive supportive management.