A 61-year-old woman with a history of Roux-en-y gastric bypass for morbid obesity presents with dysphagia and vomiting. She undergoes esophagogastroscopy at an outside institution where food impaction at the level of the gastrojejunostomy is found. A push-and-pull technique is used to remove the food. During the course of endoscopy, bleeding at the level of the upper esophageal sphincter is noted. After the procedure, the patient complains of sub-sternal chest pain.
A few hours later, crepitus is noted at the level of the sternal notch extending to both angles of the jaw. She has clear breath sounds bilaterally, and her abdomen is non-tender. She remains afebrile, but is tachycardic with a heart rate in the 120s. She has a leukocytosis with a white blood cell count of 20,000.
Esophageal perforation occurs in a variety of clinical scenarios. Iatrogenic trauma of the esophagus is the leading cause of esophageal perforation, with instrumentation accounting for approximately two-thirds of all cases. Instrumentation includes esophagoscopy, by far the leading iatrogenic cause, as well as pneumatic dilatation and bougienage. The risk of esophageal perforation with esophagoscopy alone is 0.03%, and rises to between 1% and 5% for endoscopic procedures such as variceal sclerotherapy and pneumatic dilatation for achalasia.1
Spontaneous perforation accounts for approximately 15% of esophageal ruptures and is the next leading etiology after esophageal instrumentation. Less common causes of esophageal perforation include foreign body ingestion, penetrating trauma, and neoplasm.
The esophagus originates at the level of the cricopharyngeus in the neck, traverses the posterior mediastinum, and ends in the upper abdomen just underneath the esophageal hiatus. Esophageal perforations can occur at any level, and the location often dictates the symptoms and the severity of the illness. While cervical perforations are tolerated relatively well, thoracic esophageal perforations and the ensuing mediastinal sepsis are potentially lethal if not promptly addressed.
Esophagoscopy most commonly perforates the esophagus at the level of the upper esophageal sphincter, which is the narrowest section. The esophagus is also prone to perforation at the level of the left mainstem bronchus and the gastroesophageal junction, the two other sections of esophageal narrowing.
Spontaneous perforations of the esophagus typically arise after violent vomiting or retching. The perforation is usually located in the distal esophagus just short of the gastroesophageal junction. The perforation is often directed toward the left, which is predisposed to disruption from the pathologic intraluminal pressure generated against a closed upper esophageal sphincter.
Esophageal perforation may lead to contamination of the deep cervical and prevertebral fascial planes, posterior mediastinum, pleural cavities, and peritoneum. A chemical inflammatory response is rapidly followed by local and systemic septic responses, as oropharngyeal flora contaminate the tissues surrounding the perforation. The mediastinal pleura is easily disrupted by the inflammation and leads to complicated pleural effusions and ...