Esophageal Rupture

Aka: Esophageal Rupture, Esophageal Perforation, Boerhaave's Syndrome, Boerhaave Syndrome, Esophageal Tear

1. Pathophysiology
   1. Rupture results in linear tear of the lower esophagus
   2. Following rupture, only mediastinal pleura contains esophageal contents
      1. Lower esophagus lacks serosal covering
   3. Esophageal contents leaks into mediastinum, resulting in cardiopulmonary and systemic findings
      1. Pressure gradient changes with respirations
   4. Severe inflammation and infection follows
      1. Mediastinitis
      2. Empyema (following spread to pleural space)
2. Epidemiology
   1. Rare (but lethal if unrecognized)
3. Causes
   1. Esophageal Cancer
   2. Esophageal Foreign Body
   3. Sudden increase in esophageal pressure
      1. Severe Retching or Vomiting (Mallory-Weis Tear)
      2. Valsalva Maneuver
   4. Traumatic Injury
      1. Upper endosccopy
      2. Penetrating Chest Trauma
      3. Blunt force to left chest, Sternum or epigastrium
         1. Forces gastric contents into the esophagus
4. Precautions
   1. Consider in the injured patient with a left Pneumothorax or Hemothorax without a Rib Fracture
5. Findings: Presentations
   1. Mackler's Triad (occurs in <50% of patients)
      1. Severe Vomiting
      2. Chest Pain
      3. Subcutaneous Emphysema
6. Symptoms
   1. Melena
   2. Vomiting
      1. Retching
      2. Hematemesis
   3. Chest Pain (70% of cases, most common presenting symptom)
      1. Follows Retching, Valsalva Maneuver or other sudden increase in esophageal pressure
      2. Pain distribution depends on perforation location
         1. Cervical Esophageal Perforation
            1. Dysphagia
            2. Pain increases with Swallowing or neck flexion
         2. Thoracic Esophageal Perforation
            1. Retrosternal pain radiates to back or epigastrium
         3. Distal Esophageal Perforation
            1. Pain radiation into Shoulders from diaphragmatic irritation
            2. Peritonitis if esophageal contents leak into Abdomen
7. Signs
   1. Sudden collapse and patient appears acutely ill
      1. Fever (delayed onset in up to 50% of cases)
      2. Shock
      3. Tachycardia
   2. Signs develop only gradually
      1. Subcutaneous Emphysema
      2. Mediastinal air
      3. Hamman's Crunch
      4. Pleural Effusion
      5. Pneumothorax
8. Labs
   1. Broad based labs are typically performed as for any critically ill patient
      1. However diagnosis is based on imaging
   2. Complete Blood Count (CBC)
      1. Leukocytosis
9. Diagnostics
   1. Nasogastric Tube
      1. Aspirate with bloody fluid
   2. Chest XRay (Test Sensitivity: 90%)
      1. Anterior displacement of trachea
      2. Subcutaneous Emphysema
      3. Pneumomediastinum (Mediastinal air, Mediastinal Emphysema)
         1. Pathognomonic of Esophageal Rupture
      4. V-Sign
         1. Air outlines the medial left hemidiaphragm and lower mediastinal margin
      5. Pleural Effusion (esp. left sided)
      6. Wide Mediastinum
      7. Pneumothorax
         1. When Trauma-related it is often left sided and without Rib Fracture
         2. Chest Tube will show continued air leak and particulate matter
      8. Other findings
         1. Mediastinal air fluid level
         2. Free air under diaphragm
   3. Chest CT with IV Contrast (or CT Esophagography)
      1. Test Sensitivity: 92 to 100%
      2. Preferred study in patients stable enough to undergo CT imaging
      3. Guides surgical management, evaluates for associated injury, and excludes other causes
   4. Other studies (if CT imaging non-diagnostic)
      1. Esophagram (Gastrografin or dilute barium)
      2. Gastroscopy (False Negatives not uncommon)
10. Management
    1. Emergent surgical intervention
       1. Survival rates are best with the earliest interventions (within hours of onset)
       2. Wide mediastinal drainage and esophageal wall repair is often required
          1. However, minimally invasive procedures may be indicated in some cases
    2. ABC Management
       1. Aggressive fluid Resuscitation (and Vasopressors as needed) for shock
       2. Perform Endotracheal Intubation early in unstable patients (esp. with subcutaneous Emphysema)
       3. Avoid Noninvasive Ventilation (BiPAP, NIPPV)
          1. May worsen Esophageal Perforation and subcutaneous Emphysema
    3. Broad spectrum antibiotics
       1. Drug 1: Vancomycin
       2. Drug 2 (Choose 1)
          1. Piperacillin/Tazobactam (Zosyn) OR
          2. Meropenem OR
          3. Cefepime and Metronidazole
       3. Antifungal indications (consult infectious disease)
          1. Immunocompromised patient
          2. Prior esophageal infection
          3. Chronic Proton Pump Inhibitor (PPI)
    4. Prevent increases in esophageal pressure via symptom management
       1. Antiemetics (e.g. IV Ondansetron)
       2. Opioid Analgesics
    5. Other measures
       1. Keep patient NPO
       2. Proton Pump Inhibitor (e.g. IV Pantoprazole)
       3. Chest Tube for contaminated (esophageal contents) Pleural Effusion drainage
       4. Avoid Nasogastric Tube placement if possible
          1. Perform only under direction of managing surgical team
          2. Risk of increasing esophageal pressures on placement (Gag Reflex)
          3. Difficult placement and possible misplacement via perforation
11. Resources
    1. Kassem (2021) Esophageal Perforation And Tears, StatPearls, Treasure Island
       1. https://www.ncbi.nlm.nih.gov/books/NBK532298/
12. References
    1. (2012) ATLS, 9th Ed, American College of Surgeons, Committee on Trauma, p. 108
    2. Long and Swaminathan in Swadron (2022) EM:Rap 22(7): 13-5