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  • Clinician

Esophageal perforation

Summary

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. Diagnosis of esophageal perforation is confirmed via neck or chest x-ray, esophagram, and/or CT of the neck and chest. 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).

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Etiology

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
    • Intake of large amounts of alcohol or food in the recent past
    • Repeated episodes of vomiting
    • Childbirth
    • Seizures
    • Prolonged coughing
    • Weightlifting
  • 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.

Clinical features

Diagnostics

Approach: : If esophageal perforation or Boerhaave syndrome is suspected, a neck or a chest x-ray is first conducted; . If inconclusive, an esophagram and/or CT scan is conducted to confirm the diagnosis [1][2]

  1. Initial diagnostic study
  2. Confirmatory test that reveals location and size of rupture
    • Contrast esophagography (gold standard): Contrast leak [3]
  3. If the patient is unstable/uncooperative, pneumoperitoneum is detected on x-ray, or x-rays and contrast esophagography are inconclusive
  4. If CT scan is inconclusive
    • Consider flexible endoscopy: should be reserved for patients with a poorly localized esophageal perforation and those with a therapeutic indication for endoscopy.

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Initial approach [1][2][4]

Nonsurgical treatment [1][2][4]

  • 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][4]

  • Indications
    • Hemodynamic instability
    • Patients who do not fulfill the criteria for conservative management
    • Clinical deterioration during conservative management
  • Surgical repair
    • Closure of the ruptured esophageal segment
    • Last resort: esophagectomy

Acute management checklist

Complications

Mediastinitis

Others

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

Prognosis

  • 1. Mavroudis CD, Kucharczuk JC. Acute Management of Esophageal Perforation. Current Surgery Reports. 2013; 2(1). doi: 10.1007/s40137-013-0034-x.
  • 2. Kaman L. Management of Esophageal Perforation in Adults. Gastroenterology Research. 2011. doi: 10.4021/gr263w.
  • 3. Søreide J, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19(1): p. 66. doi: 10.1186/1757-7241-19-66.
  • 4. Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgical, endoscopic and medical management strategies. Curr Opin Gastroenterol. 2010; 26(4): pp. 379–383. doi: 10.1097/mog.0b013e32833ae2d7.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
  • Giuli R. The Esophagogastric Junction: 420 Questions, 420 Answers. John Libbey Eurotext; 1998.
  • Kluge J. Die akute und chronische Mediastinitis. Der Chirurg. 2016; 87(6): pp. 469–477. doi: 10.1007/s00104-016-0172-7.
  • Athanassiadi KA. Infections of the Mediastinum. Thorac Surg Clin. 2009; 19(1): pp. 37–45. doi: 10.1016/j.thorsurg.2008.09.012.
  • Schooneveld TV. Mediastinitis. https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/infectious-diseases/mediastinitis/. Updated January 1, 2017. Accessed April 18, 2020.
last updated 07/14/2020
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