Esophageal perforation

Last updated: October 27, 2022

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Perforation of the esophagus is most commonly caused by upper endoscopy (iatrogenic), foreign body ingestion, or trauma. It can be located at any point along the esophagus, in the cervical, thoracic, or abdominal region. Boerhaave syndrome is a spontaneous subtype of esophageal perforation characterized by transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure. The condition is associated with recent consumption of large amounts of alcohol or food, repeated episodes of vomiting, and other causes of elevated intrathoracic pressure (e.g., childbirth, seizure, prolonged coughing). The classic symptom is severe retrosternal pain, which is due to the development of mediastinal emphysema after massive emesis. Evidence of esophageal perforation may be seen on neck, chest, and/or abdominal x-ray and the diagnosis is confirmed with esophagram and/or CT esophagography. Surgical repair of the esophageal rupture is often necessary, although conservative treatment alone may be considered in select cases (e.g., if the perforation is very small and the patient is stable).

Epidemiological data refers to the US, unless otherwise specified.

Esophageal perforation (general) [1][2]

  • Iatrogenic esophageal perforation
    • Most common cause of esophageal perforation
    • Most often injury during upper endoscopy
    • Injury related to surgery
  • Ingestion of a foreign body or caustic material
    • Bone, dentures
    • Alkali or acidic agents (e.g., batteries)
  • Trauma (blunt or penetrating)
  • Malignancy
  • Infection
  • Spontaneous rupture

Boerhaave syndrome

  • Risk factors
  • Pathophysiology
    • Severe vomiting/increased intrathoracic pressure → rupture of all layers of the esophageal wall (transmural perforation)
    • In > 90% of cases, the rupture occurs in the distal third of the esophagus on the left dorsolateral wall surface.

Symptoms are often nonspecific; maintain a high index of suspicion in patients with recent retching, vomiting, upper endoscopy, trauma, or known esophageal or mediastinal malignancy.

In suspected esophageal perforation or Boerhaave syndrome, x-ray of the chest, abdomen, and/or neck is first conducted, followed by contrast esophagography. If inconclusive, or the patient is unstable or unable to cooperate, a CT scan is conducted to confirm the diagnosis. [1][2]

Imaging

Initial diagnostic studies

As radiographic abnormalities may not be immediately apparent after injury, negative results on early plain x-rays do not rule out acute perforation. [3]

Confirmatory tests

The differential diagnoses listed here are not exhaustive.

Initial management [1][3][8]

Do not attempt blind nasogastric tube placement to avoid further damage to the esophagus. [9][11]

Patients with esophageal perforation can deteriorate rapidly and benefit from close monitoring in the ICU and early surgical consultation. [3]

Nonsurgical treatment [1][2][8]

  • Indications
    • Small, contained perforation, demonstrated by:
    • The perforation site is benign, outside of the abdomen, and distal to an obstruction.
    • The patient is stable with no evidence of sepsis.
    • Contrast studies are available at any time for follow-up evaluation.
    • A skilled thoracic surgeon is continuously available.
  • Consider endoscopic intervention
    • Esophageal stent placement
    • Endoclip
    • Fibrin glue application

Surgical treatment [1][2][8]

Mediastinitis

Consider acute mediastinitis in any patient with recent cardiothoracic surgery, deep neck infection, or potential esophageal injury who presents with chest pain and/or sepsis. [13][18]

Early diagnosis and treatment are essential to prevent significant morbidity and mortality associated with acute mediastinitis. [15]

Others

We list the most important complications. The selection is not exhaustive.

  • Mortality: 10–50% [2]
  1. Mavroudis CD, Kucharczuk JC. Acute Management of Esophageal Perforation. Curr Surg Rep. 2013; 2 (1). doi: 10.1007/s40137-013-0034-x . | Open in Read by QxMD
  2. Kaman L. Management of Esophageal Perforation in Adults. Gastroenterol Res. 2011 . doi: 10.4021/gr263w . | Open in Read by QxMD
  3. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  4. Levy AD, Carucci LR, Bartel TB, et al. ACR Appropriateness Criteria® Dysphagia. Journal of the American College of Radiology. 2019; 16 (5): p.S104-S115. doi: 10.1016/j.jacr.2019.02.007 . | Open in Read by QxMD
  5. Søreide J, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19 (1): p.66. doi: 10.1186/1757-7241-19-66 . | Open in Read by QxMD
  6. Norton-Gregory AA, Kulkarni NM, O’Connor SD, et al. CT Esophagography for Evaluation of Esophageal Perforation. RadioGraphics. 2021; 41 (2): p.447-461. doi: 10.1148/rg.2021200132 . | Open in Read by QxMD
  7. Wei CJ, Levenson RB, Lee KS. Diagnostic Utility of CT and Fluoroscopic Esophagography for Suspected Esophageal Perforation in the Emergency Department. Am J Roentgenol. 2020; 215 (3): p.631-638. doi: 10.2214/ajr.19.22166 . | Open in Read by QxMD
  8. Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgical, endoscopic and medical management strategies. Curr Opin Gastroenterol. 2010; 26 (4): p.379-383. doi: 10.1097/mog.0b013e32833ae2d7 . | Open in Read by QxMD
  9. DeVivo A, Sheng AY, Koyfman A, Long B. High risk and low prevalence diseases: Esophageal perforation. Am J Emerg Med. 2022; 53 : p.29-36. doi: 10.1016/j.ajem.2021.12.017 . | Open in Read by QxMD
  10. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin Therapeutic Guidelines: A Summary of Consensus Recommendations from the Infectious Diseases Society of America, the American Society of Health‐System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis. 2009; 49 (3): p.325-327. doi: 10.1086/600877 . | Open in Read by QxMD
  11. Chirica M, Kelly MD, Siboni S, et al. Esophageal emergencies: WSES guidelines. World J Emerg Surg. 2019; 14 (1). doi: 10.1186/s13017-019-0245-2 . | Open in Read by QxMD
  12. Kluge J. Acute and chronic mediastinitis. Chirurg. 2016; 87 (6): p.469-477. doi: 10.1007/s00104-016-0172-7 . | Open in Read by QxMD
  13. Athanassiadi KA. Infections of the Mediastinum. Thorac Surg Clin. 2009; 19 (1): p.37-45. doi: 10.1016/j.thorsurg.2008.09.012 . | Open in Read by QxMD
  14. Mediastinitis. https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/infectious-diseases/mediastinitis/. Updated: January 1, 2017. Accessed: April 18, 2020.
  15. Pastene B, Cassir N, Tankel J, et al. Mediastinitis in the intensive care unit patient: a narrative review. Clin Microbiol Infect. 2020; 26 (1): p.26-34. doi: 10.1016/j.cmi.2019.07.005 . | Open in Read by QxMD
  16. Exarhos DN, Malagari K, Tsatalou EG, et al. Acute mediastinitis: spectrum of computed tomography findings. Eur Radiol. 2004; 15 (8): p.1569-1574. doi: 10.1007/s00330-004-2538-3 . | Open in Read by QxMD
  17. Abu-Omar Y, Kocher GJ, Bosco P, et al. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg. 2017; 51 (1): p.10-29. doi: 10.1093/ejcts/ezw326 . | Open in Read by QxMD
  18. van Wingerden JJ, Maas M, Braam RL, de Mol BA. Diagnosing poststernotomy mediastinitis in the ED. Am J Emerg Med. 2016; 34 (3): p.618-622. doi: 10.1016/j.ajem.2015.12.048 . | Open in Read by QxMD
  19. Giuli R. The Esophagogastric Junction: 420 Questions, 420 Answers. John Libbey Eurotext ; 1998

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