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A. Etiology

  1. Iatrogenic - esophageal (balloon) dilatation procedures
  2. Cancer - usually primary esophageal neoplasm
  3. Trauma
  4. Spontaneous - Boerhave's (usually associated with severe vomiting)
  5. Corrosive esophagitis (acid or alkali ingestion)
  6. Esophageal ulcer
  7. Mallory-Weiss Tare
    1. Mucosal (superficial) tear usually caused by vomiting and retching
    2. Leads to dysphagia and bleeding, not perforation

B. Symptoms and Progression

  1. Pain - usually retrosternal, worsened by swallowing and breathing
  2. Little hemoptysis or hematemesis in most cases
  3. Secondary infection occurs rapidly, with severe pain and erythema
    1. Severe mediastinitus due to bacteria, gastric acid and digestive enzymes
    2. Mediastinal abscess may develop
    3. Pleuropulmonary supperative complications may develop
  4. Rapid progression then occurs
    1. Unless in neck, will be dead within 24-48 hours without surgical treatement
    2. Organisms from human mouth flora cause very severe, virulent infections

C. Diagnosis

  1. Mediastinal cracking sounds on auscultation
  2. Radiograph or CT scan may show subcutaneous emphysemia in neck, mediastinum
  3. Gastrograffin swallow is acceptable first study in questionable cases [3]
    1. However, some (~20%) of esophageal perforations will be missed
    2. Therefore, high suspicion and negative gastrograffin study is followed by barium study
    3. Care should be taken to prevent aspiration of gastrograffin
    4. Aspiration causes pulmonary edema, pneumonitis, and can lead to death
  4. Barium contrast swallow
    1. Relatively safe if perforation present
    2. Should be avoided with large (obvious) tears

D. Treatment

  1. Surgical emergency
  2. Emergent Supportive Care
    1. All patients should be given nothing by mouth (NPO)
    2. Place large bore intravenous lines
    3. Chest Tube as needed
  3. All patients receive prophylactic antibiotics
    1. Imipenam-cilistatin or Meropenam
    2. Ampicillin-Sulbactam (Unasyn®)
    3. Clindamycin - third line due to increased risk of Clostridium difficile
  4. Boerhaave's Syndrome [4]
    1. Primary surgical esophageal repair is very effective
    2. Mediastinal toilet and drainage is used also
    3. Drainage gastrostomy is placed
    4. May be effective in patients with >24 hours of rupture
  5. Expanding Esophageal Mesh Stent [5]
    1. May be placed emergently to bridge the esophageal trear
    2. Chest and mediastinal drainage is also required
    3. Esophagus may heal itself under these conditions
  6. Neck: surgical repair and drain
  7. Chest and abdomen
    1. Surgical Repair
    2. Gastrostomy Tube to drain
    3. Jejunostomy Tube for feeding
    4. Thoracotomy
    5. OR diversion - cervical esophagostomy until repair
  8. Glucocorticoids, antibiotics and early bougienage does not improve outcomes in treatment of esophageal burns due to acid or alkali [6]

References

  1. Kim-Deobald J and Kozarek RA. 1992. Am J Gastroenterol. 87(9):1112 abstract
  2. Ghahremani GG. 1993. Radiol Clin North Am. 31(6):1219 abstract
  3. Buecker A, Wein BB, Neuerburg JM, Guenther RW. 1997. Radiology. 202(3):683 abstract
  4. Lawrence DR, Ohri SK, Moxon RE, et al. 1999. Ann Thoracic Surg. 67(3):818 abstract
  5. Davies AP and Vaughan R. 1999. Ann Thoracic Surg. 67(5):1482 abstract
  6. Karnak I, Tanyel FC, Buyukpamuku N, Hicsonmez A. 1999. J Cardiovasc Surg. 40(2):307 abstract