II. Pathophysiology
- Rupture results in linear tear of the Esophagus
- Most commonly occurs in the left mid-thoracic Esophagus
- Following rupture, only mediastinal pleura contains esophageal contents
- Lower Esophagus lacks serosal covering
- Esophageal contents leaks into mediastinum, resulting in cardiopulmonary and systemic findings
- Pressure gradient changes with respirations
- Severe inflammation and infection follows
- Mediastinitis
- Empyema (following spread to pleural space)
III. Epidemiology
- Rare (but lethal if unrecognized)
IV. Causes
- Esophageal Cancer
- Esophageal Foreign Body (e.g. Button Battery, bones, oral retainers, dentures or other dental prostheses)
- Caustic Ingestion
- Severe Esophagitis from opportunistic infections (e.g. Candida, HSV)
- Sudden increase in esophageal pressure
- Severe Retching or Vomiting (Mallory-Weis Tear)
- Valsalva Maneuver
-
Traumatic Injury
- Penetrating Chest Trauma
- Blunt force to left chest, Sternum or epigastrium
- Forces gastric contents into the Esophagus
- Spinal Injury (cervical or Thoracic Spine Trauma)
- Iatrogenic Injury associated with procedures
- Upper endosccopy
- Esophageal dilation
- Esophageal biopsy
- Esophageal intubation
- Nasogastric Tube Placement
- Transesophageal Echocardiogram (TEE)
- Thoracic, Spine or Mediastinal Surgery
V. Precautions
- Consider in the injured patient with a left Pneumothorax or Hemothorax without a Rib Fracture
VI. Findings: Presentations
- Mackler's Triad (occurs in <50% of patients)
- Severe Vomiting
- Chest Pain
- Subcutaneous Emphysema
VII. Symptoms
- Melena
- Vomiting
-
Chest Pain (70% of cases, most common presenting symptom)
- Follows Retching, Valsalva Maneuver or other sudden increase in esophageal pressure
- Pain distribution depends on perforation location
- Cervical Esophageal Perforation
- Dysphagia
- Pain increases with Swallowing or neck flexion
- Thoracic Esophageal Perforation
- Retrosternal pain radiates to back or epigastrium
- Distal Esophageal Perforation
- Cervical Esophageal Perforation
- Other associated symptoms
VIII. Signs
- Sudden collapse and patient appears acutely ill
- Fever (delayed onset in up to 50% of cases)
- Shock
- Tachycardia
- Signs develop only gradually
- Subcutaneous Emphysema
- Mediastinal air
- Hamman's Crunch
- Pleural Effusion
- Pneumothorax
IX. Labs
- Broad based labs are typically performed as for any critically ill patient
- However diagnosis is based on imaging
- Complete Blood Count (CBC)
X. Diagnostics
-
Nasogastric Tube
- Aspirate with bloody fluid
-
Chest XRay (Test Sensitivity: 90%)
- Anterior displacement of trachea
- Subcutaneous Emphysema
- Pneumomediastinum (Mediastinal air, Mediastinal Emphysema)
- Pathognomonic of Esophageal Rupture
- V-Sign
- Air outlines the medial left hemidiaphragm and lower mediastinal margin
- Pleural Effusion (esp. left sided)
- Wide Mediastinum
- Pneumothorax
- When Trauma-related it is often left sided and without Rib Fracture
- Chest Tube will show continued air leak and particulate matter
- Other findings
- Mediastinal air fluid level
- Free air under diaphragm
-
Chest CT with IV Contrast (or CT Esophagography)
- Test Sensitivity: 92 to 100%
- Preferred study in patients stable enough to undergo CT imaging
- Guides surgical management, evaluates for associated injury, and excludes other causes
- Other studies (if CT imaging non-diagnostic)
- Esophagram (Gastrografin or dilute barium)
- Gastroscopy (False Negatives not uncommon)
XI. Management
- Emergent surgical intervention
- Survival rates are best with the earliest interventions (within hours of onset)
- Wide mediastinal drainage and esophageal wall repair is often required
- However, minimally invasive procedures may be indicated in some cases
-
ABC Management
- Aggressive fluid Resuscitation (and Vasopressors as needed) for shock
- Perform Endotracheal Intubation early in Unstable Patients (esp. with subcutaneous Emphysema)
- Avoid Noninvasive Ventilation (BiPAP, NIPPV)
- May worsen Esophageal Perforation and subcutaneous Emphysema
- Broad spectrum Antibiotics
- Drug 1: Vancomycin
- Drug 2 (Choose 1)
- Piperacillin/Tazobactam (Zosyn) OR
- Meropenem OR
- Cefepime and Metronidazole
- Antifungal indications (consult infectious disease)
- Immunocompromised patient
- Prior esophageal infection
- Chronic Proton Pump Inhibitor (PPI)
- Prevent increases in esophageal pressure via symptom management
- Antiemetics (e.g. IV Ondansetron)
- Opioid Analgesics
- Other measures
- Keep patient NPO
- Proton Pump Inhibitor (e.g. IV Pantoprazole)
- Chest Tube for contaminated (esophageal contents) Pleural Effusion drainage
- Avoid Nasogastric Tube placement if possible
- Perform only under direction of managing surgical team
- Risk of increasing esophageal pressures on placement (Gag Reflex)
- Difficult placement and possible misplacement via perforation
XII. Resources
- Kassem (2021) Esophageal Perforation And Tears, StatPearls, Treasure Island