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Esophageal perforation

Last updated: December 9, 2020

Summary

Perforation of the esophagus is most commonly caused by upper endoscopy (iatrogenic), foreign body ingestion, or trauma. It can be located at any point along the esophagus, in the cervical, thoracic, or abdominal region. Boerhaave syndrome is a spontaneous subtype of esophageal perforation characterized by transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure. The condition is associated with recent consumption of large amounts of alcohol or food, repeated episodes of vomiting, and other causes of elevated intrathoracic pressure (e.g., childbirth, seizure, prolonged coughing). The classic symptom is severe retrosternal pain, which is due to the development of mediastinal emphysema after massive emesis. Diagnosis of esophageal perforation is confirmed via neck or chest x-ray, esophagram, and/or CT of the neck and chest. Surgical repair of the esophageal rupture is often necessary, although conservative treatment alone may be considered in select cases (e.g., if the perforation is very small and the patient is stable).

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Esophageal perforation (general) [1][2]

  • Iatrogenic esophageal perforation
    • Most common cause of esophageal perforation
    • Most often injury during upper endoscopy
    • Injury related to surgery
  • Ingestion of a foreign body or caustic material
    • Bone, dentures
    • Alkali or acidic agents (e.g., batteries)
  • Trauma (blunt or penetrating)
  • Malignancy
  • Infection
  • Spontaneous rupture

Boerhaave syndrome

  • Risk factors
    • Intake of large amounts of alcohol or food in the recent past
    • Repeated episodes of vomiting
    • Prolonged coughing
    • Childbirth
    • Seizures
    • Weightlifting
  • Pathophysiology
    • Severe vomiting/increased intrathoracic pressure → rupture of all layers of the esophageal wall (transmural perforation)
    • In > 90% of cases, the rupture occurs in the distal third of the esophagus on the left dorsolateral wall surface.

Clinical features

Diagnostics

If esophageal perforation or Boerhaave syndrome is suspected, a neck or a chest x-ray is first conducted, followed by contrast esophagography; . If inconclusive, or the patient is unstable/uncooperative, a CT scan is conducted to confirm the diagnosis. [1][2]

Imaging

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Initial approach [1][2][4]

Nonsurgical treatment [1][2][4]

  • Indications
    • Small, contained perforation, demonstrated by:
    • The perforation site is benign, outside of the abdomen, and distal to an obstruction.
    • The patient is stable with no evidence of sepsis.
    • Contrast studies are available at any time for follow-up evaluation.
    • A skilled thoracic surgeon is continuously available.
  • Consider endoscopic intervention
    • Esophageal stent placement
    • Endoclip
    • Fibrin glue application

Surgical treatment [1][2][4]

Acute management checklist

Complications

Mediastinitis

Others

We list the most important complications. The selection is not exhaustive.

Prognosis

References

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  2. Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011 . doi: 10.4021/gr263w . | Open in Read by QxMD
  3. Søreide J, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19 (1): p.66. doi: 10.1186/1757-7241-19-66 . | Open in Read by QxMD
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  7. Mediastinitis. https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/infectious-diseases/mediastinitis/. Updated: January 1, 2017. Accessed: April 18, 2020.
  8. Abu-Omar Y, Kocher GJ, Bosco P, et al. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. European Journal of Cardio-Thoracic Surgery. 2017; 51 (1): p.10-29. doi: 10.1093/ejcts/ezw326 . | Open in Read by QxMD
  9. Exarhos DN, Malagari K, Tsatalou EG, et al. Acute mediastinitis: spectrum of computed tomography findings. Eur Radiol. 2004; 15 (8): p.1569-1574. doi: 10.1007/s00330-004-2538-3 . | Open in Read by QxMD
  10. Herold G. Internal Medicine. Herold G ; 2014
  11. Giuli R. The Esophagogastric Junction: 420 Questions, 420 Answers. John Libbey Eurotext ; 1998