Esophageal perforation

Background

• Full thickness perforation of the esophagus
• Secondary to sudden increase in esophageal pressure

Causes

• Iatrogenic
• Boerhaave syndrome
• Thoracic Trauma
  • Penetrating
  • Blunt (rare)
• Caustic ingestion
• Foreign body
  • Bone, button battery
• Infection (rare)
• Tumor
• Aortic pathology
• Barrett esophagus
• Zollinger-Ellison syndrome

Clinical Features

• Mackler’s triad of chest pain, vomiting and subcutaneous emphysema is pathognomonic for Boerhaave syndrome

History

• Pain
  • Acute, severe, unrelenting, diffuse
  • May be localized to chest, neck, abdomen; radiate to back and shoulders
  • Occurs suddenly after foreceful vomiting
• Dysphagia
• Dyspnea
• Hematemesis

Physical Exam

• Cervical subcutaenous emphysema
• Mediastinal emphysema
  • Takes time to develop
  • Absence does not rule out perforation
  • Hamman's sign - crunching sound during heart beat

Differential Diagnosis

Chest pain

Critical

• Acute Coronary Syndromes
  • STEMI
  • Non-STEMI
  • Unstable angina
• Aortic Dissection
• Cardiac Tamponade
• Pulmonary Embolism
• Tension Pneumothorax
• Boerhhaave's Syndrome
• Coronary Artery Dissection

Emergent

• Pericarditis
• Myocarditis
• Pneumothorax
• Mediastinitis
• Cholecystitis
• Pancreatitis
• Cocaine-associated chest pain

Nonemergent

• Stable angina
• Asthma exacerbation
• Valvular Heart Disease
• Aortic Stenosis
• Mitral valve prolapse
• Hypertrophic cardiomyopathy
• Pneumonia
• Pleuritis
• Tumor
• Pneumomediastinum
• Esophageal Spasm
• Gastroesophageal Reflux Disease (GERD)
• Peptic Ulcer Disease
• Biliary Colic
• Muscle sprain
• Rib Fracture
• Arthritis
• Chostochondirits
• Spinal Root Compression
• Thoracic outlet syndrome
• Herpes Zoster / Postherpetic Neuralgia
• Psychologic / Somatic Chest Pain
• Hyperventilation
• Panic attack

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragm injury
  • Hemothorax
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac contusion
  • Cardiac trauma
  • Cardiac tamponade
  • Commotio cordis
    • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Flail chest
  • Rib fracture
  • Scapula fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • 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
• CT chest: may show pneumomediastinum, but will not show perforation
• Esophagram with water soluble contrast for definitive diagnosis
• Emergent endoscopy, but may worsen the tear during insufflation

Management

• Volume resuscitation
• Broad-spectrum IV antibiotics
• Emergent surgical consultation

See Also

• Esophageal Injury

References

Authors

Daniel Eggeman, Jordan Swartz, Ross Donaldson, Kevin Lu, Neil Young