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Esophageal Rupture
Aka: Esophageal Rupture, Esophageal Perforation, Boerhaave's Syndrome, Esophageal Tear
- Pathophysiology
- Rupture results in linear tear of the lower esophagus
- Following rupture, only mediastinal pleura contains esophageal contents
- Lower esophagus lacks serosal covering
- Esophageal contents leaks into mediastinum
- Pressure gradient changes with respirations
- Severe inflammation and infection follows
- Mediastinitis
- Empyema (following spread to pleural space)
- Epidemiology
- Rare (but lethal if unrecongized)
- Causes
- Esophageal Cancer
- Esophageal Foreign Body
- Severe Retching or Vomiting (Mallory-Weis Tear)
- Traumatic Injury
- Penetrating Chest Trauma
- Blunt force to left chest, Sternum or epigastrium
- Forces gastric contents into the esophagus
- Precautions
- Consider in the injured patient with a left Pneumothorax or Hemothorax without a Rib Fracture
- Symptoms
- Melena
- Vomiting
- Retching
- Hematemesis
- Chest Pain
- Follows Retching
- Retrosternal pain radiates to back or epigastrium
- Pain increases with Swallowing or neck movement
- Signs
- Sudden collapse and patient appears acutely ill
- Shock
- Fever
- Tachycardia
- Signs develop only gradually
- Subcutaneous Emphysema
- Mediastinal air
- Hamman's Crunch
- Pleural Effusion
- Labs
- Complete Blood Count (CBC)
- Leukocytosis
- Diagnostics
- Nasogastric Tube
- Aspirate with bloody fluid
- Chest XRay
- Anterior displacement of trachea
- Mediastinal air (Mediastinal Emphysema)
- Pathognomonic of Esophageal Rupture
- Pleural Effusion
- 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 studies
- Esophagram (Gastrografin or dilute barium)
- Gastroscopy (False Negatives not uncommon)
- Chest CT
- Management
- Emergent surgical intervention
- Survival rates are best with the earliest interventions (within hours of onset)
- Wide mediastinal drainage and esophageal wall repair
- References
- (2012) ATLS, 9th Ed, American College of Surgeons, Committee on Trauma, p. 108