Esophagus

Esophageal Rupture

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

  • 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
    1. Pressure gradient changes with respirations
  4. Severe inflammation and infection follows
    1. Mediastinitis
    2. Empyema (following spread to pleural space)
  • Epidemiology
  1. Rare (but lethal if unrecongized)
  • Causes
  1. Esophageal Cancer
  2. Esophageal Foreign Body
  3. Severe Retching or Vomiting (Mallory-Weis Tear)
  4. Traumatic Injury
    1. Penetrating Chest Trauma
    2. Blunt force to left chest, Sternum or epigastrium
      1. Forces gastric contents into the esophagus
  • Precautions
  1. Consider in the injured patient with a left Pneumothorax or Hemothorax without a Rib Fracture
  • Symptoms
  1. Melena
  2. Vomiting
    1. Retching
    2. Hematemesis
  3. Chest Pain
    1. Follows Retching
    2. Retrosternal pain radiates to back or epigastrium
    3. Pain increases with swallowing or neck movement
  • Signs
  1. Sudden collapse and patient appears acutely ill
    1. Shock
    2. Fever
    3. Tachycardia
  2. Signs develop only gradually
    1. Subcutaneous Emphysema
    2. Mediastinal air
    3. Hamman's Crunch
    4. Pleural Effusion
  • Labs
  1. Complete Blood Count (CBC)
    1. Leukocytosis
  • Diagnostics
  1. Nasogastric Tube
    1. Aspirate with bloody fluid
  2. Chest XRay
    1. Anterior displacement of trachea
    2. Mediastinal air (Mediastinal Emphysema)
      1. Pathognomonic of Esophageal Rupture
    3. Pleural Effusion
    4. Wide Mediastinum
    5. 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
  3. Other studies
    1. Esophagram (Gastrografin or dilute barium)
    2. Gastroscopy (false negatives not uncommon)
    3. Chest CT
  • 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
  • References
  1. (2012) ATLS, 9th Ed, American College of Surgeons, Committee on Trauma, p. 108