Esophageal Perforation

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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"

Laboratory Findings

• • 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

Imaging Findings

• • 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

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

Rule Out

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

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

  • Plain chest films

  • Esophagogram with water soluble contrast material

When to Admit

• • All cases

• • Antibiotics should be given immediately

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

Surgery