Esophageal rupture resident survival guide

Jump to navigation Jump to search
Esophageal rupture Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ibtisam Ashraf, M.B.B.S.[2]

Synonyms and Keywords: Approach to esophageal perforation, Boerhaave syndrome workup, Esophageal rupture workup

Overview

Esophageal rupture is a severe condition often caused by esophageal instrumentation, including endoscopy. It also occurs from forceful vomiting, retching and swallowing of the foreign body resulting in leakage of air, stomach acid and food content into the mediastinum. Such spontaneous rupture is also known as Boerhaave syndrome. This leakage leads to severe inflammation of mediastinum called mediastinitis and pleural effusion. Symptoms can range from chest pain, dyspnea, hematemesis to hypotension and shock. Time is crucial when diagnosing the rupture of the esophagus since it impacts the complication that emerges from it. The reason for this is the specific position of the esophagus, resulting in severe mediastinitis, empyema, and septic shock during leakage of bacteria and digestive enzymes. Esophageal injuries arising from penetrating trauma are frequently associated with injuries to other organs such as the liver, spleen, aorta, vena cava, diaphragm and lungs. Diagnostic modalities include CT Scan, esophagography with water-based contrast and flexible esophagoscopy. Treatment requires surgical reconstruction of perforation, and the procedure is highly dependent on the location of the injury. (i.e. cervical, thoracic, etc.) However, endoscopic stent or placement of internal or external drains is considered when the clinical situation allows for a less invasive approach.

Causes

Life Threatening Cause

Life-threatening cause includes the condition that may result in death or permanent disability within 24 hours if left untreated.

  • Traumatic injury to the esophagus that is secondary to penetrating or blunt forces including gun shot wounds. [1]

Common Causes


Diagnosis

Chest pain is the most commonly occurring symptom. It can be sudden in onset with radiation to the back or the left shoulder. Additional symptoms include vomiting and shortness of breath. The triad of vomiting, chest pain and subcutaneous emphysema is known as the Mackler triad.[2]

On Physical Examination, tachycardia is usual with fever (> 38.5 ° C) as a later sign. Attention should be given as to whether there is crepitus in the neck area or on the chest wall, as this is typical of subcutaneous emphysema. Systemic inflammatory response typically develops rapidly after perforation, usually within 24-48 hours, and severe bacterial mediastinitis may cause cardiopulmonary collapse and multiple organ failure (MOF) with a catastrophic outcome within a limited period of time.[3]

 
 
 
 
 
 
 
 
Clinical suspicion for
esophageal injury
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamically
Stable
 
Hemodynamically
unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT Scan of the Neck (Oral and IV
Contrast, if possible)
 
Trauma exploration
including endoscopy
to identify any injuries.
Esophageal Repair or Drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT Findings
consistent with injury
to esophagus
 
 
 
No Esophageal
injury identified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopy to identify esophageal
injury with or without bronchoscopy
based on triage of other injuries
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Injury Identified
 
 
No Injury Identified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical Exploration.
Esophageal repair or drainage
 
 
Observe, trial
of clear liquids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pain with
swallowing?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopy to identify esophagal
injury. If endoscopy recently
performed, obtain esophagogram.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Injury Identified
 
No Injury Identified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical Exploration.
Esophageal repair or drainage
 
Supportive treatment and
Observation
 
 
 
 
 
 
 

Treatment

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Instrumental Perforation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical Examination
Resuscitation
Imaging & Endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Free Perforation with
mediastinal contamination
and sepsis
 
 
 
 
 
 
 
 
 
 
 
 
Contained Perofration
Clinically stable Paitent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Operative
Treatment
 
 
 
 
 
 
 
 
 
 
 
 
Non-operative management
Percutaneous drainage
as needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malignant
Obstruction
 
 
 
 
Benign
Obstruction
 
 
 
 
 
No
Obstruction
 
 
 
 
Improvement
and
Recovery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary Repair
Reinforcement
Myotomy
Antireflux procedure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non
disseminated
 
Advanced
disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ResectionEndoscopic stent
Palliation
 
 
 
 
 
 
 
 
 
 


 
 
 
 
 
 
 
 
 
 
Spontaneous Perforation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical Examination
Resuscitation
Imaging & Endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Contained perforation
with severe
mediastinal contamination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Contained rupture with minimal
mediastinal contamination
or
Late presentation in a patient
in good clinical
condition
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thoracotomy,
debridement
and irrigation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NPO
IV Antibiotics
Nasogastric decompression
Enteral tube nutrition/
total parental nutrition
Tube thoracostomy
Carefull clinical observation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement
and
Recovery
 
 
 
 
 
 
 
Early
presentation,
primary repair
suitable
Late
presentation,
unsuitable for
primary repair
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary repair
+/-reinforcement
T-tube fistula or
Resection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Feeding jejunostomy
Optimal intensive care(ICU)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

Don'ts

  • Delay the treatment since mortality and morbidity is directly related to the delay in diagnosis and initiation of optimum treatment.
  • Eat or drink until the treatment is completed.

References

  1. "Esophageal Perforation, Rupture, And Tears - StatPearls - NCBI Bookshelf".
  2. MACKLER SA (September 1952). "Spontaneous rupture of the esophagus; an experimental and clinical study". Surg Gynecol Obstet. 95 (3): 345–56. PMID 14950670.
  3. Søreide JA, Viste A (October 2011). "Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours". Scand J Trauma Resusc Emerg Med. 19: 66. doi:10.1186/1757-7241-19-66. PMC 3219576. PMID 22035338.