Esophageal perforation

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Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.
Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.
Esophagus anatomy and nomenclature based on two systems.
  • Also known as "Boerhaave syndrome"
  • Full thickness perforation of the esophagus
  • Secondary to sudden increase in esophageal pressure
  • Perforation is usually posterolateral

Causes

Clinical Features

Mackler's Triad

Pathognomonic for Boerhaave syndrome

  1. Chest pain
    • Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagusMackler triad[1]
    • Usually acute and sudden in onset
    • May be worse on neck flexion or with swallowing
    • Radiation to the back or to the left shoulder
  2. Vomiting (+/- shortness of breath)
    • In about 25% of the patientsMackler triad[2]
  3. Subcutaneous emphysema
    • Palpable in up to 60% of patients[3]

Other Possible Symptoms

  • Neck pain
    • When cervical esophagus is perforated
  • Dysphonia, hoarseness, dysphagia
  • Acute abdominal or epigastric pain
    • Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melenaMackler triad[4]
  • Fever is a late sign

Later Signs (Generally within 24-48 Hour)

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Thoracic Trauma

Evaluation

Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.
Gastrografin esophagram showing a leak into the left thoracic cavity.
Perforation of the esophagus seen on swallow study.

Imaging

  • CXR: 90% will have radiographic abnormalities, nonspecific in nature[5]
  • Esophagram
    • Water soluble contrast (e.g., diatrizoate meglumine and diatrizoate sodium solution)
    • Preferred study as it allows for definitive diagnosis
  • CT chest
    • May show pneumomediastinum
    • Will not definitively show perforation
  • Emergent endoscopy
    • May worsen the tear during insufflation

Management

Disposition

  • Admit (generally to OR for emergent repair)

See Also

External Links


References

  1. ↑ Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66,
  2. ↑ Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66,
  3. ↑ Kaman L, Iqbal J, Kundil B, Kochhar R. Management of Esophageal Perforation in Adults. Gastroenterology Res. 2010;3(6):235-244. doi:10.4021/gr263w
  4. ↑ Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66,
  5. ↑ Hess JM, Lowell MJ: Esophagus, Stomach and Duodenum, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 89: p 1170-1187
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