Diagnosis

Esophageal perforation

Etiology

Cause [oqu][qtv]

• Iatrogenic: Endoscopy, dilatation, tamponade tubes, resection, radiotherapy

• Vomiting (Boerhaave syndrome)

• Mallory-Weiss syndrome

• Foreign body ingestion

• Esophageal ulcer

• Eosinophilic esophagitis

• Trauma

• Esophageal cancer

• Ingestion of corrosive substances

Pathophysiology [qtv]

1. The esophagus is anatomically divided into 3 regions based on blood syupply:

   • The cervical esophagus

   • The thoracic esophagus

   • The abdominal esophagus

2. Esophageal perforations can arise in any of the 3 natural constrictions:

   • Cervical: The cricopharyngeal sphincter at the level of the C6 vertebra

   • Thoracic: Where the esophagus is crossed by the aortic arch and left bronchus

   • Diaphragmatic: Where the esophagus pierces the diaphragm at the T10 vertebra

3. Intraluminal injuries:

   • Instrumentation

   • Ingestion of foreign bodies

   • Esophagitis and carcinoma

   • Infection or barotrauma

4. Extraluminal injuries

   • Traumatic injuries

   • Surgical accidents/Iatrogenic injuries: fundoplication or esophageal myotomy

5. Perforation --> leak of contents (gastric contents, saliva, biliary fluid):

   • Chemical mediastinitis

   • Mediastinal emphysema

   • Bacterial translocation

   • Exudative pleural effusion

   • Sepsis/shock

Complications [oqu][qtv]

• Sepsis

• Mediastinitis

• Intrathoracic abscess

• Respiratory failure

• Shock

• 90-day mortality: 22-39% [cko]

Epidemiology

Incidence per 100.000 [cko][ds7][c8f][pyq][wmn]

Approach

• Chest x-ray

• Contrast esophagography/Barium enema

• Gastroscopy

• CT thorax

• Thoracentesis (low pH, elevated amylase)

Treatment

1. Initial therapy: [fon][qtv] Conservative if absence of infection and contained perforation

   • Admission to ICU: Hemodynamic monitoring, volume resuscitation, and stabilizatio

   • Nasogastric suction

   • Parenteral nutrition

   • Intravenous broad-spectrum antibiotics and antifungals

   • Intravenous proton pump inhibitors

   • Percutaneous drainage of any fluid collections

   • Feeding jejunostomy tube

   • Analgesic

2. Endoscopic: [cko][qou][qtv]

   • Stent + Thoracic drain

   • Endoluminal negative-pressure therapy

   • Endoscopic fibrin sealant

   • Endoscopic suture ligation

3. Open surgery: [fon][cko][oqu]

   • Primary repair ± local flap (transthoracic or transhiatal) + Thoracic drain

   • Esophageal resection + pericardial/pleural flap

   • Cervical esophagostomy:

     • Diversion prevents further contamination

     • High morbidity of the procedure

     • Reserved for unstable patient, major disruption of the esophageal wall, severe contamination

Differential diagnoses

Achalasia, Acute pancreatitis, Aortic dissection, Esophageal cancer, Esophageal diverticula, Esophageal spasm, Gastroesophageal reflux disease, Mallory-Weiss tear, Myocardial infarction, Perforated ulcer, Pericarditis, Pleural empyema, Pneumonia, Pneumonitis, Pneumothorax, Pulmonary embolism