Esophageal perforation: Difference between revisions
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==Clinical Features==
==Clinical Features==
===Mackler triad===
#[[Chest pain]]
#*Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagus
#*Usually acute and sudden in onset
#*Radiation to the back or to the left shoulder
#Vomiting (+/- shortness of breath)
#*In about 25% of the patients
#Subcutaneous emphysema
===Other Possible Symptoms===
*Neck pain when cervical esophagus is perforated
*Dysphonia, hoarseness, cervical dysphagia
*Acute abdominal or epigastric pain
**Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melena
*Fever is a late sign
===Later Signs (Generally within 24-48 Hour)===
*SIRS
*Sepsis
*Overwhelming bacterial mediastinitis
*Multiple organ failure
*Death


==Mackler’s triad==
==Mackler’s triad==

Revision as of 19:37, 1 November 2023

Background

  • Full thickness perforation of the esophagus
  • Secondary to sudden increase in esophageal pressure
  • Perforation is usually posterolateral

Causes

Clinical Features

Mackler triad

  1. Chest pain
    • Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagus
    • Usually acute and sudden in onset
    • Radiation to the back or to the left shoulder
  2. Vomiting (+/- shortness of breath)
    • In about 25% of the patients
  3. Subcutaneous emphysema

Other Possible Symptoms

  • Neck pain when cervical esophagus is perforated
  • Dysphonia, hoarseness, cervical dysphagia
  • Acute abdominal or epigastric pain
    • Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melena
  • Fever is a late sign

Later Signs (Generally within 24-48 Hour)

  • SIRS
  • Sepsis
  • Overwhelming bacterial mediastinitis
  • Multiple organ failure
  • Death

Mackler’s triad

History

  • Pain
    • Acute, severe, unrelenting, diffuse
    • May be worse on neck flexion or with swallowing
    • May be localized to chest, neck, abdomen; radiate to back and shoulders
    • Occurs suddenly, often after forceful vomiting
  • Dysphagia
  • Dyspnea
  • Hematemesis

Physical Exam

  • Cervical subcutaneous emphysema
  • Mediastinal emphysema
    • Takes time to develop
    • Absence does not rule out perforation
    • Hamman's sign
      • Mediastinal crunching sound
  • May rapidly develop sepsis due to mediastinitis

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Thoracic Trauma

Evaluation

Imaging

  • CXR: 90% will have radiographic abnormalities, nonspecific in nature[2]
Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.
  • Esophagram
    • Water soluble contrast (e.g., diatrizoate meglumine and diatrizoate sodium solution)
    • Preferred study as it allows for definitive diagnosis
  • CT chest
    • May show pneumomediastinum
    • Will not definitively show perforation
  • Emergent endoscopy
    • May worsen the tear during insufflation

Management

Disposition

  • Admit (generally to OR for emergent repair)

See Also

External Links


References

  1. ↑ Kaman L, Iqbal J, Kundil B, Kochhar R. Management of Esophageal Perforation in Adults. Gastroenterology Res. 2010;3(6):235-244. doi:10.4021/gr263w
  2. ↑ Hess JM, Lowell MJ: Esophagus, Stomach and Duodenum, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 89: p 1170-1187
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