Esophageal perforation: Difference between revisions
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==Background==
==Background==
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]]
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]]
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]]
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]]
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*Secondary to sudden increase in esophageal pressure
*Secondary to sudden increase in esophageal pressure
*Perforation is usually posterolateral
*Perforation is usually posterolateral


===Causes===
===Causes===
*Iatrogenic (most common)
*Iatrogenic (most common)
**Endoscopy
**Endoscopy
*[[Boerhaave syndrome]]
*[[Special:MyLanguage/Boerhaave syndrome|Boerhaave syndrome]]
*[[Thoracic Trauma]]
*[[Special:MyLanguage/Thoracic Trauma|Thoracic Trauma]]
**Penetrating
**Penetrating
**Blunt (rare)
**Blunt (rare)
*[[Caustic ingestion]]
*[[Special:MyLanguage/Caustic ingestion|Caustic ingestion]]
*[[ingested foreign body|Foreign body]]
*[[Special:MyLanguage/ingested foreign body|Foreign body]]
**Bone
**Bone
**Button battery
**Button battery
*[[Infection]] (rare)
*[[Special:MyLanguage/Infection|Infection]] (rare)
*Tumor
*Tumor
*Aortic pathology
*Aortic pathology
*Barrett esophagus
*Barrett esophagus
*[[Zollinger-Ellison syndrome]]
*[[Special:MyLanguage/Zollinger-Ellison syndrome|Zollinger-Ellison syndrome]]
 


==Clinical Features==
==Clinical Features==
===Mackler's Triad===
===Mackler's Triad===
''Pathognomonic for Boerhaave syndrome''
''Pathognomonic for Boerhaave syndrome''
#[[Chest pain]]
#[[Special:MyLanguage/Chest pain|Chest pain]]
#*Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagusMackler triad<ref>Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66, </ref>
#*Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagusMackler triad<ref>Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66, </ref>
#*Usually acute and sudden in onset
#*Usually acute and sudden in onset
#*May be worse on neck flexion or with swallowing
#*May be worse on neck flexion or with swallowing
#*Radiation to the back or to the left shoulder
#*Radiation to the back or to the left shoulder
#[[Vomiting]] (+/- [[shortness of breath]])
#[[Special:MyLanguage/Vomiting|Vomiting]] (+/- [[Special:MyLanguage/shortness of breath|shortness of breath]])
#*In about 25% of the patientsMackler triad<ref>Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66, </ref>
#*In about 25% of the patientsMackler triad<ref>Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66, </ref>
#[[Subcutaneous emphysema]]
#[[Special:MyLanguage/Subcutaneous emphysema|Subcutaneous emphysema]]
#*Palpable in up to 60% of patients<ref>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</ref>
#*Palpable in up to 60% of patients<ref>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</ref>


===Other Possible Symptoms===
===Other Possible Symptoms===
*[[Neck pain]]
 
*[[Special:MyLanguage/Neck pain|Neck pain]]
**When cervical esophagus is perforated
**When cervical esophagus is perforated
*Dysphonia, hoarseness, [[dysphagia]]
*Dysphonia, hoarseness, [[Special:MyLanguage/dysphagia|dysphagia]]
*Acute abdominal or [[epigastric pain]]
*Acute abdominal or [[Special:MyLanguage/epigastric pain|epigastric pain]]
**Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melenaMackler triad<ref>Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66, </ref>
**Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melenaMackler triad<ref>Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66, </ref>
*[[Fever]] is a late sign
*[[Special:MyLanguage/Fever|Fever]] is a late sign
 


===Later Signs (Generally within 24-48 Hour)===
===Later Signs (Generally within 24-48 Hour)===
*[[SIRS]]
 
*[[Sepsis]]
*[[Special:MyLanguage/SIRS|SIRS]]
*Overwhelming bacterial [[mediastinitis]]  
*[[Special:MyLanguage/Sepsis|Sepsis]]
*Overwhelming bacterial [[Special:MyLanguage/mediastinitis|mediastinitis]]  
**Hamman's sign  
**Hamman's sign  
*Multiple organ failure  
*Multiple organ failure  
*[[Death]]
*[[Special:MyLanguage/Death|Death]]
 


==Differential Diagnosis==
==Differential Diagnosis==
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{{Chest Pain DDX}}
{{Chest Pain DDX}}
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</translate>
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}
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==Evaluation==
==Evaluation==
[[File:Boerhaave.jpg|thumbnail|Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.]]
[[File:Boerhaave.jpg|thumbnail|Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.]]
[[File:Fig2-A-gastrografin-esophagram-shows-a-leak-to-the-left-thoracic-cavity.jpg|thumb|Gastrografin esophagram showing a leak into the left thoracic cavity.]]
[[File:Fig2-A-gastrografin-esophagram-shows-a-leak-to-the-left-thoracic-cavity.jpg|thumb|Gastrografin esophagram showing a leak into the left thoracic cavity.]]
[[File:Eso perforation.jpg|thumb|Perforation of the esophagus seen on swallow study.]]
[[File:Eso perforation.jpg|thumb|Perforation of the esophagus seen on swallow study.]]
===Imaging===
===Imaging===
*[[CXR]]: 90% will have radiographic abnormalities, nonspecific in nature<ref>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</ref>
 
**[[Pneumomediastinum]]
*[[Special:MyLanguage/CXR|CXR]]: 90% will have radiographic abnormalities, nonspecific in nature<ref>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</ref>
**[[Special:MyLanguage/Pneumomediastinum|Pneumomediastinum]]
**Abnormal cardiomediastinal contour
**Abnormal cardiomediastinal contour
**[[Pneumothorax]]
**[[Special:MyLanguage/Pneumothorax|Pneumothorax]]
**[[Pleural effusion]]
**[[Special:MyLanguage/Pleural effusion|Pleural effusion]]
*Esophagram
*Esophagram
**Water soluble contrast (e.g., diatrizoate meglumine and diatrizoate sodium solution)
**Water soluble contrast (e.g., diatrizoate meglumine and diatrizoate sodium solution)
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*Emergent endoscopy
*Emergent endoscopy
**May worsen the tear during insufflation
**May worsen the tear during insufflation


==Management==
==Management==
*[[Volume resuscitation]]
 
*Broad-spectrum IV [[antibiotics]]
*[[Special:MyLanguage/Volume resuscitation|Volume resuscitation]]
*Broad-spectrum IV [[Special:MyLanguage/antibiotics|antibiotics]]
**ex. Piperacillin/tazobactam + Vancomycin  
**ex. Piperacillin/tazobactam + Vancomycin  
*Emergent surgical consultation
*Emergent surgical consultation


==Disposition==
==Disposition==
*Admit (generally to OR for emergent repair)
*Admit (generally to OR for emergent repair)


==See Also==
==See Also==
*[[Ingested foreign body]]
 
*[[Esophageal Injury]]
*[[Special:MyLanguage/Ingested foreign body|Ingested foreign body]]
*[[Special:MyLanguage/Esophageal Injury|Esophageal Injury]]
 


==External Links==
==External Links==
*[http://www.emdocs.net/esophageal-perforation-pearls-and-pitfalls-for-the-resuscitation-room/ emDocs - Esophageal Perforation: Pearls and Pitfalls for the Resuscitation Room]
*[http://www.emdocs.net/esophageal-perforation-pearls-and-pitfalls-for-the-resuscitation-room/ emDocs - Esophageal Perforation: Pearls and Pitfalls for the Resuscitation Room]
*[https://coreem.net/podcast/episode-66-0/ CORE EM - Boerhaave Syndrome]
*[https://coreem.net/podcast/episode-66-0/ CORE EM - Boerhaave Syndrome]




==References==
==References==
<references/>
<references/>
[[Category:GI]]
[[Category:GI]]
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Latest revision as of 22:53, 4 January 2026


Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.
Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.
Esophagus anatomy and nomenclature based on two systems.
  • Also known as "Boerhaave syndrome"
  • Full thickness perforation of the esophagus
  • Secondary to sudden increase in esophageal pressure
  • Perforation is usually posterolateral


Causes


Clinical Features

Mackler's Triad

Pathognomonic for Boerhaave syndrome

  1. Chest pain
    • Present in more than 70% of patients with a full thickness perforation of the intrathoracic esophagusMackler triad[1]
    • Usually acute and sudden in onset
    • May be worse on neck flexion or with swallowing
    • Radiation to the back or to the left shoulder
  2. Vomiting (+/- shortness of breath)
    • In about 25% of the patientsMackler triad[2]
  3. Subcutaneous emphysema
    • Palpable in up to 60% of patients[3]


Other Possible Symptoms

  • Neck pain
    • When cervical esophagus is perforated
  • Dysphonia, hoarseness, dysphagia
  • Acute abdominal or epigastric pain
    • Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melenaMackler triad[4]
  • Fever is a late sign


Later Signs (Generally within 24-48 Hour)


Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Thoracic Trauma


Evaluation

Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.
Gastrografin esophagram showing a leak into the left thoracic cavity.
Perforation of the esophagus seen on swallow study.

Imaging

  • CXR: 90% will have radiographic abnormalities, nonspecific in nature[5]
  • 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. ↑ Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66,
  2. ↑ Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66,
  3. ↑ 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
  4. ↑ Søreidecorresponding JA, et al. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19:66. doi: 10.1186/1757-7241-19-66,
  5. ↑ 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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