Esophageal perforation: Difference between revisions
No edit summary
Line 24: Line 24:


==Clinical Features==
==Clinical Features==
===Mackler triad===
===Mackler's Triad===
''Pathognomonic for [[Boerhaave syndrome]]''
#[[Chest pain]]
#[[Chest pain]]
#*Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagusMackler triad<ref>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, </ref>
#*Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagusMackler triad<ref>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, </ref>
Line 32: Line 33:
#*In about 25% of the patientsMackler triad<ref>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, </ref>
#*In about 25% of the patientsMackler triad<ref>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, </ref>
#[[Subcutaneous emphysema]]
#[[Subcutaneous emphysema]]
***Palpable in up to 60% of patients<ref>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</ref>


===Other Possible Symptoms===
===Other Possible Symptoms===
Line 48: Line 50:
*[[Death]]
*[[Death]]


==Mackler’s triad==
*Pathognomonic for [[Boerhaave syndrome]]
**[[Chest pain]]
**[[Vomiting]]
**Subcutaneous emphysema
***Palpable in up to 60% of patients<ref>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</ref>


===History===
===History===

Revision as of 20:07, 1 November 2023

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.
  • 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
    • 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, cervical 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)


History

  • Pain
    • Acute, severe, unrelenting, diffuse
    • May be worse on neck flexion or with swallowing
    • May be localized to chest, neck, abdomen; radiate to back and shoulders
    • Occurs suddenly, often after forceful vomiting
  • Dysphagia
  • Dyspnea
  • Hematemesis

Physical Exam

  • Cervical subcutaneous emphysema
  • Mediastinal emphysema
    • Takes time to develop
    • Absence does not rule out perforation
    • Hamman's sign
      • Mediastinal crunching sound
  • May rapidly develop sepsis due to mediastinitis

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
Retrieved from "https://www.wikem.org/w/index.php?title=Esophageal_perforation&oldid=371863"