Esophageal perforation: Difference between revisions

No edit summary
(28 intermediate revisions by 7 users not shown)
Line 1: Line 1:
==Causes==
==Background==
#Iatrogenic
*Full thickness perforation of the esophagus
#Boerhaave syndrome
*Secondary to sudden increase in esophageal pressure
#Trauma
*Perforation is usually posterolateral
##Penetrating
##Blunt (rare)
===Causes===
#Caustic ingestion
*Iatrogenic (most common)
#Foreign body
**Endoscopy
##Bone, button battery
*[[Boerhaave syndrome]]
#Infection (rare)
*[[Thoracic Trauma]]
#Tumor
**Penetrating
#Aortic pathology
**Blunt (rare)
#Barrett esophagus
*[[Caustic ingestion]]
#Zollinger-Ellison syndrome
*[[ingested foreign body|Foreign body]]
**Bone
**Button battery
*[[Infection]] (rare)
*Tumor
*Aortic pathology
*Barrett esophagus
*[[Zollinger-Ellison syndrome]]
 
==Clinical Features==
 
==Mackler’s triad==
*Pathognomonic for [[Boerhaave syndrome]]
**[[Chest pain]]
**[[Vomiting]]
**Subcutaneous emphysema


==Diagnosis==
===History===
===History===
*Pain
*[[chest pain|Pain]]
**Acute, severe, unrelenting, diffuse
**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
**May be localized to chest, neck, abdomen; radiate to back and shoulders
*Dysphagia
**Occurs suddenly, often after forceful vomiting
*Dyspnea
*[[Dysphagia]]
*Hematemesis
*[[Dyspnea]]
*[[Hematemesis]]
 
===Physical Exam===
===Physical Exam===
*Cervical subcutaenous emphysema
*Cervical subcutaneous emphysema
*Mediastinal emphysema
*Mediastinal emphysema
**Takes time to develop
**Takes time to develop
**Absence does not rule out perforation
**Absence does not rule out perforation
===Imaging===
**Hamman's sign
*CXR
***Mediastinal crunching sound
*May rapidly develop [[sepsis]] due to [[mediastinitis]]
 
==Differential Diagnosis==
{{Chest Pain DDX}}
{{Thoracic trauma DDX}}
 
==Evaluation==
===Imaging<ref>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</ref>===
*[[CXR]]: 90% will have radiographic abnormalities, nonspecific in nature
[[File:Boerhaave.jpg|thumbnail|Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.]]
**[[Pneumomediastinum]]
**Abnormal cardiomediastinal contour
**[[Pneumothorax]]
**[[Pleural effusion]]
*Esophagram
**Water soluble contrast
**Preferred study as it allows for definitive diagnosis
*CT chest
*CT chest
**May show pneumomediastinum
**Will not definitively show perforation
*Emergent endoscopy
*Emergent endoscopy
**May worsen the tear during insufflation


==DDx==
==Management==
#ACS
*[[Volume resuscitation]]
#PE
*Broad-spectrum IV [[antibiotics]]
#Aortic catastrophe
*Emergent surgical consultation
#Acute abdomen
#Peptic ulcer disease
 
==Treatment==
#Volume resuscitation
#Broad-spectrum IV Abx
#Emergent surgical consultation


==Disposition==
==Disposition==
*Admit (generally to OR for emergent repair)


==See Also==
==See Also==
*[[Ingested foreign body]]
*[[Esophageal Injury]]


==Source==
==References==
Tintinalli
<references/>
 
[[Category:GI]]
[[Category:GI]]

Revision as of 23:18, 14 February 2021

Background

  • Full thickness perforation of the esophagus
  • Secondary to sudden increase in esophageal pressure
  • Perforation is usually posterolateral

Causes

Clinical Features

Mackler’s triad

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

Imaging[1]

  • CXR: 90% will have radiographic abnormalities, nonspecific in nature
Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.
  • Esophagram
    • Water soluble contrast
    • 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

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