Author(s): Sophia Savva and Andrew Dixon
Causes of oesophageal perforation and rupture are given in Table 75.1.
Typical presentation is vomiting followed by severe lower retrosternal chest pain in a middle-aged male, often with a background of heavy alcohol intake. Oesophageal rupture may occur without vomiting, and may follow straining (e.g. in labour or with weight-lifting), coughing or hiccoughing. Often there is an underlying diagnosis of eosinophilic oesophagitis or Barrett's oesophagus.
Pneumomediastinum may result in subcutaneous emphysema (found in ∼25% patients) and crackling sounds on auscultation of the heart. There may be signs of pleural effusion/pneumothorax. Signs of septic shock (from mediastinitis) may dominate the clinical picture and are seen in ∼25% of patients at presentation.
Includes myocardial infarction, aortic dissection, pulmonary embolism, pericarditis, pneumonia, spontaneous pneumothorax, perforated peptic ulcer, acute pancreatitis. Misdiagnosis of spontaneous oesophageal rupture is common.
- Urgent surgical opinion
- Admit to high-dependency unit (HDU)/intensive care unit (ICU)
- Nil by mouth
- Opioid analgesia and antiemetic
- IV fluids
- Antibiotic therapy to cover anaerobic and Gram-positive/Gram-negative aerobic bacteria: for example piperacillin/tazobactam + metronidazole + gentamicin
- IV proton pump inhibitor
- Management of septic shock if present (Chapter 35)
- Small tears at the gastro-oesophageal junction.
- Accounts for 5–10% of acute upper gastrointestinal bleeding (chapter 73).
- A history of retching is only elicited in around 30% of cases.
- Around 80% stop bleeding spontaneously and rebleeding is uncommon outside of the context of coagulopathy.
- Rarely need endoscopic therapy except if high-risk stigmata are present, for example visible vessel.
Usually caused by large pieces of meat or small chicken or fish bones.
Patients present with sudden onset dysphagia and a sensation of a blockage.
Chest pain due to muscle spasm is common and can mimic angina.
AP and lateral chest X-rays are useful to asses for mediastinal free air.
Most pass spontaneously, but due to the potential for localized ischaemia within the oesophagus, endoscopy should be performed within 12 hours.
Underlying oesophageal pathology has been reported in 80%, including benign and malignant strictures, dysmotility and eosinophilic oesophagitis (diagnosed on biopsy).
Once the obstruction has been cleared hospitalization is rarely necessary, although repeat outpatient endoscopy is sometimes indicated (e.g. for stricture dilatation).