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Uvular necrosis: a rare complication of upper gastrointestinal endoscopy

A 57-year-old male underwent routine upper gastrointestinal endoscopy (UGIE) for clinical suspicion of gastro-oesophageal reflux disorder (GORD). He was otherwise well, with no medical history. The gastroscopy was completed to the second part of the duodenum. The Z-line was irregular with histological evidence of mild inflammation. The stomach and duodenum were unremarkable with no helicobacter pylori organisms identified. His was commenced on proton pump inhibitor monotherapy. Twenty-fourhours after the procedure, the patient presented to the hospital with hoarseness of voice, sore throat, and dysphagia. He noted an enlarged and erythematous uvula. There was no airway compromise or abdominal pain. He was initially managed as a potential anaphylactic reaction in the emergency department with adrenaline nebuliser and intravenous dexamethasone. However, clinical examination was consistent with necrosis of uvula. The distal portion of the uvula had partially sloughed off (Fig. 1). Symptomatic management with paracetamol, soft diet and antiseptic mouthwash was advised. Resolution was achieved without further intervention within a week. Uvular necrosis is a rare complication of endotracheal intubation or upper gastrointestinal endoscopy. It may also occur because of vigorous oral suctioning. The aetiology is pressure necrosis secondary to impingement between iatrogenic instrumentation and the hard palate. There is potential risk of developing deeper ulceration, bleeding, and oropharyngeal sepsis. It is typically selflimiting with recovery within 2 weeks. Less than 10 cases have been reported in the last two decades on literature review. Conservative management and cautious observation are recommended. Topical anaesthetic agents may improve discomfort. Prophylactic antibiotics are unlikely to provide significant benefit. Uvular necrosis should be cautioned for in gastroscopy. It can be selectively identified as a particular risk in male patients, the elderly, and those with an elongated uvula. Operator technique also plays a role. Endoscopy, however, remains the gold standard for diagnosis of GORD.