• History of recent instrumentation of the esophagus or severe vomiting
• Pain in the neck, chest, or upper abdomen
• Signs of mediastinal or thoracic sepsis within 24 hours
• Contrast radiographic evidence of an esophageal leak
• Crepitus and subcutaneous emphysema of the neck in some cases
• Esophageal perforations can result from instrumentation, severe vomiting, and external trauma
• Morbidity is principally due infection
• Immediately after injury, infection has not become established
• 24 hours after perforation, infection will have occurred and the esophageal defect usually breaks down if it is closed
• Instrumental perforations are most likely to occur in the cervical esophagus
• Spontaneous perforation usually occurs in the left posterolateral aspect 3-5 cm above the gastroesophageal junction and typically involves the pleura
• Thoracic perforations are most common at the level of the left main-stem bronchus and diaphragmatic hiatus
• Cervical perforations: Pain is followed by crepitus in the neck, dysphagia, and signs of infection
• Thoracic perforations: Tachypnea, hyperpnea, dyspnea, and hypotension
• With pleural perforation, pneumothorax is produced followed by hydrothorax and, if not promptly treated, empyema
• Escape of air into the mediastinum may result in a "mediastinal crunch"
• Radiographs for cervical perforation
-Air in the soft tissues, especially along the cervical spine
-Trachea may be displaced anteriorly by air and fluid
-Later, widening of the superior mediastinum may be seen
• Radiographs for thoracic perforations
• An esophagogram using water-soluble contrast medium should be performed promptly in order to confirm level and extent of injury
• Antibiotics should be given immediately
• Definitive therapy (eg, resection) should be performed in patients with other surgical conditions (carcinoma)
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