A cautionary tale for home brewers

especially those who use old kegs and those who open bottles with their teeth.

Read on …

from British. Journal of. Surgery. 1987, Vol. 74, February, 151

The dangers of home-brewing: oesophageal rupture

P. J. Hainsworth

Department of Surgery, North Tyneside General Hospital,

Rake Lane, North Shields, Tyne and Wear NE298NH, UK

Correspondence to: Mr P. J. Hainsworth, Department of

Urology, Freeman Hospital, Freeman Road, High Heaton,

Newcastle upon Tyne N E 7 7 D N , UK

Blast injury to the oesophagus is rare. Previously reported cases have occurred as a result of rapidly expanding compressed air, methane, carbon monoxide or nitrogen.

Case report

A 29-year-old amateur brewer initiated fermentation in an unvented commercial aluminium beer keg. On unscrewing the plug 8 days later an explosion occurred, hurling him several feet. He developed severe chest pain, haemoptysis and became extremely dyspnoeic. Examination revealed surgical emphysema in the neck and signs of a right tension pneumothorax confirmed radiologically. Emergency treatment included intercostal drainage, nil orally, oxygen by mask and broad spectrum antibiotics.

Further examination revealed superficial facial lacerations, conjunctival hyperaemia, and marked swelling and bruising of the soft palate and tonsillar beds. An injury t o trachea or bronchus was suspected. Only after some delay was oesophageal rupture considered and confirmed by a dilute barium swallow.

Forty-eight hours after injury a right thoracotomy revealed much pleural soiling, a 5 cm longitudinal tear through mucus membrane, muscularis and pleura just below the azygos arch. Following thorough debridement the oesophagus was repaired with two layers of interrupted polyglactin and the mediastinal pleura approximated with interrupted catgut.

Three days postoperatively, having commented oral fluids, he became pyrexial, developed a large pleural effusion and drained copious amounts of turbid fluid from which Klebsiella, Escherichia and Candida species were cultured. Repeat dilute barium swallow confirmed dehiscence of the repair and he was submitted to further surgery. By this time (7 days after injury) the tissues were friable, the right lung contracted and there was no sign of the previous polyglactin sutures.

The margins of the rent excised, and an all-layers repair with continuous linen performed.

He made good progress, nasogastric feeding was commenced but, 13 days after injury, enteral feed appeared in the chest drainage.

Nevertheless feeding was continued and the chest tube withdrawn stepwise. He remains well with no stricture formation 5 months after the accident.

Discussion

This case illustrates the dangers of fermentation in an unvented closed container. The risk of oropharyngeal injury from home-made beer stored under pressure has recently been highlighted in two patients who removed bottle caps with their teeth’. The presence of oropharyngeal injury in this patient suggests that the blast wave was directed through the mouth into the upper gastrointestinal tract.

The present case unfortunately demonstrates the problem of delayed diagnosis. The clinical urgency of a large pneumothorax and acute respiratory embarrassment focused attention erroneously on .the major airways. Michel, Grillo and Matt report that, of 85 patients with oesophageal rupture, the correct diagnosis was only reached at post-mortem examination in 13 (1.5 per cent)’.

Most authors stress the importance of early diagnosis of oesophageal rupture and, although the necessity for early aggressive surgery in all patients has been questioned, there are certain caveats. Firstly, instrumental perforations during fibreoptic endoscopy form a distinct subgroup in whom early ‘active conservative’ management yields good results but this cannot be extrapolated to other aetiological groups. Secondly, successful conservative management (without drainage) has been described in patients with both cervical and thoracic perforations, but only when confined to the mediastinum with no evidence of pneumothorax, pleural effusion, sepsis, respiratory failure or shock’.

In general, surgery postponed beyond 12 h is associated with a mortality of up to 50 per cent. With delay the oesophageal wall tends to become friable and will not hold sutures and simple suture alone is associated with a high leakage rate.

Delayed diagnosis may not be a contra-indication to attempted repair, although some form of buttressing such as a pedicled pleural flap’ is probably indicated. Whether or not any procedure more complex than debridement and drainage is undertaken in delayed cases remains debatable.

Don’t say that you haven’t been warned.

DG