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  • • 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

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Epidemiology

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  • • Esophageal perforations can result from instrumentation, severe vomiting, and external trauma

    • Morbidity is principally due infection

    • Immediately after injury, infection has not become established

    • -Closure of the defect will usually prevent the development of serious infection

    • 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

    • -Pleural rupture occurs in 75% of cases

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Symptoms and Signs

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  • • Pain

    • -In the neck with cervical perforations

      -In the chest or upper abdomen with thoracic perforations

      -May radiate to the back

    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"

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Laboratory Findings

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  • • Thoracentesis will reveal cloudy or purulent fluid with elevated salivary amylase content; serum amylase levels may also be high as a result of absorption of amylase from the pleural cavity

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Imaging Findings

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  • 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

    • -Mediastinal widening and pleural effusion with or without pneumothorax

      -Mediastinal emphysema takes at least 1 hour to develop

    • An esophagogram using water-soluble contrast medium should be performed promptly in order to confirm level and extent of injury

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  • • Diagnosis should occur promptly as timing has a great influence on surgical treatment and patient survival

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Rule Out

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  • • Coexistent esophageal carcinoma, in which case the most appropriate treatment is esophagectomy

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  • • Recent history of instrumentation or forceful vomiting along with signs and symptoms of perforation

    • Plain chest films

    • Esophagogram with water soluble contrast material

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When to Admit

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  • • All cases

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  • • Antibiotics should be given immediately

    • Definitive therapy (eg, resection) should be performed in patients with other surgical conditions (carcinoma)

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Surgery

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Indications

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  • • All cases

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