Esophageal perforation: Difference between revisions

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==Background==
==Background==
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]]
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]]
[[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]]
*Also known as "Boerhaave syndrome"
*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===
*Iatrogenic
*Iatrogenic (most common)
**Endoscopy
*[[Boerhaave syndrome]]
*[[Boerhaave syndrome]]
*[[Thoracic Trauma]]
*[[Thoracic Trauma]]
**Penetrating
**Penetrating
**Blunt (rare)
**Blunt (rare)
*Caustic ingestion
*[[Caustic ingestion]]
*Foreign body
*[[ingested foreign body|Foreign body]]
**Bone, button battery
**Bone
*Infection (rare)
**Button battery
*[[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 of chest pain, vomiting and subcutaneous emphysema is pathognomonic for Boerhaave syndrome''
===Mackler's Triad===
===History===
''Pathognomonic for Boerhaave syndrome''
*Pain
#[[Chest pain]]
**Acute, severe, unrelenting, diffuse
#*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>
**May be localized to chest, neck, abdomen; radiate to back and shoulders
#*Usually acute and sudden in onset
**Occurs suddenly after foreceful vomiting
#*May be worse on neck flexion or with swallowing
*Dysphagia
#*Radiation to the back or to the left shoulder
*Dyspnea
#[[Vomiting]] (+/- [[shortness of breath]])
*Hematemesis
#*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]]
#*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===
*[[Neck pain]]
**When cervical esophagus is perforated
*Dysphonia, hoarseness, [[dysphagia]]
*Acute abdominal or [[epigastric pain]]
**Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melenaMackler 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>
*[[Fever]] is a late sign


===Physical Exam===
===Later Signs (Generally within 24-48 Hour)===
*Cervical subcutaenous emphysema
*[[SIRS]]
*Mediastinal emphysema
*[[Sepsis]]
**Takes time to develop
*Overwhelming bacterial [[mediastinitis]]
**Absence does not rule out perforation
**Hamman's sign  
**Hamman's sign - crunching sound during heart beat
*Multiple organ failure
*[[Death]]


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==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.]]
[[File:Boerhaave.jpg|thumbnail|Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.]]
**Pneumomediastinum
[[File:Fig2-A-gastrografin-esophagram-shows-a-leak-to-the-left-thoracic-cavity.jpg|thumb|Gastrografin esophagram showing a leak into the left thoracic cavity.]]
[[File:Eso perforation.jpg|thumb|Perforation of the esophagus seen on swallow study.]]
===Imaging===
*[[CXR]]: 90% will have radiographic abnormalities, nonspecific in nature<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>
**[[Pneumomediastinum]]
**Abnormal cardiomediastinal contour
**Abnormal cardiomediastinal contour
**Pneumothorax
**[[Pneumothorax]]
**Pleural effusion
**[[Pleural effusion]]
*CT chest: may show pneumomediastinum, but will not show perforation
*Esophagram
*Esophagram with water soluble contrast for definitive diagnosis
**Water soluble contrast (e.g., diatrizoate meglumine and diatrizoate sodium solution)
*Emergent endoscopy, but may worsen the tear during insufflation
**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==
==Management==
*[[Volume resuscitation]]
*[[Volume resuscitation]]
*Broad-spectrum IV [[antibiotics]]
*Broad-spectrum IV [[antibiotics]]
**ex. Piperacillin/tazobactam + Vancomycin
*Emergent surgical consultation
*Emergent surgical consultation


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


==See Also==
==See Also==
*[[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]]

Latest revision as of 22:27, 7 February 2024

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.
Esophagus anatomy and nomenclature based on two systems.
  • Also known as "Boerhaave syndrome"
  • 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
    • May be worse on neck flexion or with swallowing
    • 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, 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)

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
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