Esophageal rupture resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ibtisam Ashraf, M.B.B.S.[2]
Synonyms and keywords:esophageal, perforation, Boerhaave syndrome
Overview
Esophageal rupture is a rare but severe condition often caused by esophageal instrumentation, including endoscopy. It also occurs from forceful vomiting, retching and swallowing of the foreign body resulting in leakage of air, stomach acid and food content into the mediastinum. Such spontaneous rupture is also known as Boerhaave syndrome. This leakage leads to severe inflammation of mediastinum called mediastinitis and pleural effusion. Symptoms can range from chest pain, dyspnea, hematemesis to hypotension and shock. Time is crucial when diagnosing the rupture of the esophagus since it impacts the complication that emerges from it. Esophageal injuries arising from penetrating trauma are frequently associated with injuries to other organs such as the liver, spleen, aorta, vena cava, diaphragm and lungs. Diagnostic modalities include CT Scan, esophagography with water-based contrast and flexible esophagoscopy. Treatment requires surgical reconstruction of perforation and the procedure is highly dependent on the location of the injury. (i.e. cervical, thoracic, etc.) However, endoscopic stent or placement of internal or external drains is considered when the clinical situation allows for a less invasive approach.
Causes
Life Threatening Cause
Life-threatening cause includes the condition that may result in death or permanent disability within 24 hours if left untreated.
- Traumatic injury to the esophagus that is secondary to penetrating or blunt forces including gun shot wounds. [1]
Common Causes
- Iatrogenic Perforations
- Diagnostic endoscopy
- Flexible endoscopy
- Pneumatic dilation
- Stent placement
- Foreign body extraction
- Cancer palliation
- Endoscopic ablation techniques
- Invasive surgical manoeuvres
- Fundoplication
- Esophageal myotomy
- Spontaneous ruptures - Boerhaave syndrome
- Ruptures secondary to a foreign body impaction
- Ingestion of caustic liquids
Diagnosis
| Clinical suspicion for esophageal injury | |||||||||||||||||||||||||||||||||
| Hemodynamically Stable | Hemodynamically unstable | ||||||||||||||||||||||||||||||||
| CT Scan of the Neck (Oral and IV Contrast, if possible) | Trauma exploration including endoscopy to identify any injuries. Esophageal Repair or Drainage | ||||||||||||||||||||||||||||||||
| CT Findings consistent with injury to esophagus | No Esophageal injury identified | ||||||||||||||||||||||||||||||||
| Endoscopy to identify esophageal injury with or without bronchoscopy based on triage of other injuries | |||||||||||||||||||||||||||||||||
| Injury Identified | No Injury Identified | ||||||||||||||||||||||||||||||||
| Surgical Exploration. Esophageal repair or drainage | Observe, trial of clear liquids | ||||||||||||||||||||||||||||||||
| Pain with swallowing? | |||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||
| Endoscopy to identify esophagal injury. If endoscopy recently performed, obtain esophagogram. | |||||||||||||||||||||||||||||||||
| Injury Identified | No Injury Identified | ||||||||||||||||||||||||||||||||
| Surgical Exploration. Esophageal repair or drainage | Supportive treatment and Observation | ||||||||||||||||||||||||||||||||