Esophageal perforation: Difference between revisions

(5 intermediate revisions by 4 users not shown)
Line 2: Line 2:
*Full thickness perforation of the esophagus
*Full thickness perforation of the esophagus
*Secondary to sudden increase in esophageal pressure
*Secondary to sudden increase in esophageal pressure
*Perforation is usually posterolateral
   
   
===Causes===
===Causes===
Line 10: Line 11:
**Penetrating
**Penetrating
**Blunt (rare)
**Blunt (rare)
*Caustic ingestion
*[[Caustic ingestion]]
*Foreign body
*[[ingested foreign body|Foreign body]]
**Bone
**Bone
**Button battery
**Button battery
*Infection (rare)
*[[Infection]] (rare)
*Tumor
*Tumor
*Aortic pathology
*Aortic pathology
*Barrett esophagus
*Barrett esophagus
*Zollinger-Ellison syndrome
*[[Zollinger-Ellison syndrome]]


==Clinical Features==
==Clinical Features==


==Mackler’s triad==
==Mackler’s triad==
*Pathognomonic for Boerhaave syndrome
*Pathognomonic for [[Boerhaave syndrome]]
**Chest pain
**[[Chest pain]]
**Vomiting
**[[Vomiting]]
**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>


===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 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
**Occurs suddenly, often after forceful vomiting
**Occurs suddenly, often after forceful vomiting
*Dysphagia
*[[Dysphagia]]
*Dyspnea
*[[Dyspnea]]
*Hematemesis
*[[Hematemesis]]


===Physical Exam===
===Physical Exam===
Line 45: Line 47:
**Hamman's sign  
**Hamman's sign  
***Mediastinal crunching sound
***Mediastinal crunching sound
*May rapidly develop sepsis due to mediastinitis
*May rapidly develop [[sepsis]] due to [[mediastinitis]]


==Differential Diagnosis==
==Differential Diagnosis==
Line 55: Line 57:
*[[CXR]]: 90% will have radiographic abnormalities, nonspecific in nature
*[[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.]]
[[File:Boerhaave.jpg|thumbnail|Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.]]
**Pneumomediastinum
**[[Pneumomediastinum]]
**Abnormal cardiomediastinal contour
**Abnormal cardiomediastinal contour
**Pneumothorax
**[[Pneumothorax]]
**Pleural effusion
**[[Pleural effusion]]
*Esophagram
*Esophagram
**Water soluble contrast
**Water soluble contrast
Line 71: Line 73:
*[[Volume resuscitation]]
*[[Volume resuscitation]]
*Broad-spectrum IV [[antibiotics]]
*Broad-spectrum IV [[antibiotics]]
**ex. Piperacillin/tazobactam + Vancomycin
*Emergent surgical consultation
*Emergent surgical consultation


Line 79: Line 82:
*[[Ingested foreign body]]
*[[Ingested foreign body]]
*[[Esophageal Injury]]
*[[Esophageal Injury]]
==External Links==
*[http://www.emdocs.net/esophageal-perforation-pearls-and-pitfalls-for-the-resuscitation-room/ emDocs - Esophageal Perforation: Pearls and Pitfalls for the Resuscitation Room]
*[https://coreem.net/podcast/episode-66-0/ CORE EM - Boerhaave Syndrome]


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

Revision as of 19:16, 27 October 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[2]

  • 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

External Links


References

  1. 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
  2. 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