Esophageal perforation

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

Mackler’s triad

• Pathognomonic for Boerhaave syndrome
  • Chest pain
  • Vomiting
  • Subcutaneous emphysema
    • Palpable in up to 60% of patients

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)
  • STEMI
  • Non-STEMI
  • Unstable angina
• 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
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Evaluation

Imaging

• 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.

• • 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

• Ingested foreign body
• Esophageal Injury

External Links

• emDocs - Esophageal Perforation: Pearls and Pitfalls for the Resuscitation Room
• CORE EM - Boerhaave Syndrome