Esophageal perforation: Difference between revisions
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*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=== | ||
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**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=== | ||
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**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== | ||
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*[[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 | ||
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*[[Volume resuscitation]] | *[[Volume resuscitation]] | ||
*Broad-spectrum IV [[antibiotics]] | *Broad-spectrum IV [[antibiotics]] | ||
**ex. Piperacillin/tazobactam + Vancomycin | |||
*Emergent surgical consultation | *Emergent surgical consultation | ||
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*[[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
- Iatrogenic (most common)
- Endoscopy
- 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
- Pathognomonic for Boerhaave syndrome
- Chest pain
- Vomiting
- Subcutaneous emphysema
- Palpable in up to 60% of patients[1]
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
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Evaluation
Imaging[2]
- CXR: 90% will have radiographic abnormalities, nonspecific in nature
- Pneumomediastinum
- Abnormal cardiomediastinal contour
- Pneumothorax
- Pleural effusion
- 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
- Volume resuscitation
- Broad-spectrum IV antibiotics
- ex. Piperacillin/tazobactam + Vancomycin
- Emergent surgical consultation
Disposition
- Admit (generally to OR for emergent repair)
See Also
External Links
- emDocs - Esophageal Perforation: Pearls and Pitfalls for the Resuscitation Room
- CORE EM - Boerhaave Syndrome
References
- ↑ 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
- ↑ 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