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 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. The reason for this is the specific position of the esophagus, resulting in severe mediastinitis, empyema, and septic shock during leakage of bacteria and digestive enzymes. 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.

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

Chest pain is the most commonly occurring symptom. It can be sudden in onset with radiation to the back or the left shoulder. Additional Symptoms include vomiting and shortness of breath. The triad of vomiting, chest pain and subcutaneous emphysema is known as the Mackler triad.

On Physical Examination, tachycardia is usual with fever (> 38.5 ° C) as a later sign. Attention should be given as to whether there is crepitus in the neck area or on the chest wall, as this is typical of subcutaneous emphysema. Systemic inflammatory response typically develops rapidly after perforation, usually within 24-48 hours, and severe bacterial mediastinitis may cause cardiopulmonary collapse and multiple organ failure (MOF) with a catastrophic outcome within a limited period of time.

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

Treatment

Instrumental Perforation

Clinical Examination Resuscitation Imaging & Endoscopy

Free Perforation with mediastinal contamination and sepsis

Contained Perofration Clinically stable Paitent

Operative Treatment

Non-operative management Percutaneous drainage as needed

Malignant Obstruction

Benign Obstruction

No Obstruction

Improvement and Recovery

Primary Repair Reinforcement Myotomy Antireflux procedure

Non disseminated

Advanced disease

Resection

Endoscopic stent Palliation

Spontaneous Perforation

Clinical Examination Resuscitation Imaging & Endoscopy

Non-Contained perforation with severe mediastinal contamination

Contained rupture with minimal mediastinal contamination or Late presentation in a patient in good clinical condition

Thoracotomy, debridement and irrigation

NPO IV Antibiotics Nasogastric decompression Enteral tube nutrition/ total parental nutrition Tube thoracostomy Carefull clinical observation

Improvement and Recovery

Early presentation, primary repair suitable

Late presentation, unsuitable for primary repair

Primary repair +/-reinforcement

T-tube fistula or Resection

Feeding jejunostomy Optimal intensive care(ICU)

Do's

• Check for crepitus in the neck or the chest wall
• Check for Vital signs for shock (Low BP, Increase heart rate)
• Always manage the life-threatening conditions first incase of traumatic rupture.

Don'ts

• Delay the treatment since mortality and morbidity is directly related to the delay in diagnosis and initiation of optimum treatment.
• Eat or drink until the treatment is completed.