Esophageal rupture resident survival guide

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:esophageal, perforation, Boerhaave syndrome

Overview

Esophageal rupture is a rare but 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. 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.

Common Causes

• Iatrogenic Perforations
  • Diagnostic endoscopy
  • Flexible endoscopy
  • Pneumatic dilation
  • Stent placement
  • Foreign body extraction
  • Cancer palliation
  • Endoscopic ablation techniques
• Invasive surgical manoeuvres
  • Fundoplication
  • Esophageal myotomy
• Spontaneous ruptures - Boerhaave syndrome
• Ruptures secondary to a foreign body impaction
• Ingestion of caustic liquids

Diagnosis

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