Esophageal perforation

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Background

  • Full thickness perforation of the esophagus
  • Secondary to sudden increase in esophageal pressure

Causes

  • Iatrogenic
  • Boerhaave syndrome
  • Thoracic Trauma
    • Penetrating
    • Blunt (rare)
  • Caustic ingestion
  • Foreign body
    • Bone, button battery
  • Infection (rare)
  • Tumor
  • Aortic pathology
  • Barrett esophagus
  • Zollinger-Ellison syndrome

Clinical Features

  • Mackler’s triad of chest pain, vomiting and subcutaneous emphysema is pathognomonic for Boerhaave syndrome

History

  • Pain
    • Acute, severe, unrelenting, diffuse
    • May be localized to chest, neck, abdomen; radiate to back and shoulders
    • Occurs suddenly after foreceful vomiting
  • Dysphagia
  • Dyspnea
  • Hematemesis

Physical Exam

  • Cervical subcutaenous emphysema
  • Mediastinal emphysema
    • Takes time to develop
    • Absence does not rule out perforation
    • Hamman's sign - crunching sound during heart beat

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Thoracic Trauma

Evaluation

Imaging[1]

  • CXR: 90% will have radiographic abnormalities, nonspecific in nature
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Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.
    • Pneumomediastinum
    • Abnormal cardiomediastinal contour
    • Pneumothorax
    • Pleural effusion
  • CT chest: may show pneumomediastinum, but will not show perforation
  • Esophagram with water soluble contrast for definitive diagnosis
  • Emergent endoscopy, but may worsen the tear during insufflation

Management

See Also

References

  1. 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