Difference between revisions of "Esophageal perforation"

(Background)
 
Line 11: 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
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==Mackler’s triad==
 
==Mackler’s triad==
*Pathognomonic for Boerhaave syndrome
+
*Pathognomonic for [[Boerhaave syndrome]]
**Chest pain
+
**[[Chest pain]]
**Vomiting
+
**[[Vomiting]]
 
**Subcutaneous emphysema
 
**Subcutaneous emphysema
  
 
===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

Latest revision as of 20:37, 29 September 2019

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