49: Blunt and Penetrating Esophageal Trauma

Introduction

Esophageal trauma can result from numerous etiologies, including iatrogenic injuries from endoscopic instrumentation or other thoracic surgical procedures, penetrating or blunt trauma, caustic ingestion during suicide attempts, and even spontaneously with forceful vomiting or retching (Boerhaave syndrome).^1-3 These traumatic episodes can lead to esophageal perforation—a medical emergency that requires prompt attention. Any delay in diagnosis or treatment leads to increased patient morbidity and mortality. The signs and symptoms of esophageal trauma are presented in this chapter along with recommendations for management.

Clinical Characteristics

Esophageal perforation can result from multiple etiologies. Iatrogenic injury is the most common and results as a complication of esophageal instrumentation (50%–70% in modern series).³ Spontaneous rupture, or Boerhaave syndrome, can also occur, typically after prolonged vomiting or retching. Both blunt and penetrating injuries can lead to esophageal perforation (see Chapter 49). For the normal esophagus, the cervical portion is the most common site of injury during instrumentation.^3-7 Middle and distal esophageal injuries usually result from endoscopic stenting or dilation procedures. Iatrogenic injury sustained during endoscopic procedures such as esophagogastroduodenoscopy and transesophageal echocardiography typically are diagnosed more rapidly because the patient is under direct medical observation at the time of the injury. Although rare, esophageal perforation also can result from nasogastric tube placement, esophageal intubation with an endotracheal tube, and nonesophageal surgical procedures performed in proximity to the esophagus, such as tracheostomy, thyroidectomy, various spinal procedures, and mediastinal lymph node dissection during pulmonary resectional procedures.

Spontaneous esophageal rupture, or Boerhaave syndrome, is caused by prolonged forceful vomiting or from abrupt Valsalva-type maneuvers that abruptly increase intrathoracic pressure.^1,3 The perforation in spontaneous cases occurs in the lower esophagus posteriorly into the left chest.

Penetrating injuries to the neck can also lead to esophageal perforation. Owing to proximity to the carotid artery and trachea, penetrating esophageal injury is rarely isolated. Typically, it is associated with more immediate, life-threatening injuries to these adjacent structures.⁶ Blunt neck trauma, which can occur with either powerful direct blows to the neck or more commonly from high-speed motor vehicle accidents, usually causes an intramucosal esophageal hematoma and subsequent dysphagia but rarely perforation. Intramucosal hematomas resolve with expectant management. Full-thickness esophageal injuries can be life threatening and often are missed in this setting, clouded by other more life-threatening injuries with consequent higher morbidity and mortality.^4,6 Full-thickness esophageal injuries are associated with concurrent airway injury. A high index of suspicion is needed when evaluating trauma patients because unrecognized esophageal injury can have disastrous consequences.

Caustic esophageal injury (discussed in detail in Chapter 50) is a form of “chemically” penetrating trauma. It often results from suicide attempts, and the severity of the injury depends on the type, quantity, duration, and for children, taste of the chemical ingested. Alkaline exposure (e.g., lye) is typically more severe ...