Esophageal perforation: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
==Mackler’s triad== | |||
*Pathognomonic for Boerhaave syndrome | |||
**Chest pain | |||
**Vomiting | |||
**Subcutaneous emphysema | |||
===History=== | ===History=== | ||
*Pain | *Pain | ||
**Acute, severe, unrelenting, diffuse | **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 | **May be localized to chest, neck, abdomen; radiate to back and shoulders | ||
**Occurs suddenly after | **Occurs suddenly, often after forceful vomiting | ||
*Dysphagia | *Dysphagia | ||
*Dyspnea | *Dyspnea | ||
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===Physical Exam=== | ===Physical Exam=== | ||
*Cervical | *Cervical subcutaneous emphysema | ||
*Mediastinal emphysema | *Mediastinal emphysema | ||
**Takes time to develop | **Takes time to develop | ||
**Absence does not rule out perforation | **Absence does not rule out perforation | ||
**Hamman's sign | **Hamman's sign | ||
***Mediastinal crunching sound | |||
*May rapidly develop sepsis due to mediastinitis | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Revision as of 15:38, 19 March 2019
Background
- Full thickness perforation of the esophagus
- Secondary to sudden increase in esophageal pressure
Causes
- Iatrogenic (most common)
- Endoscopy
- Boerhaave syndrome
- Thoracic Trauma
- Penetrating
- Blunt (rare)
- Caustic ingestion
- Foreign body
- Bone
- Button battery
- Infection (rare)
- Tumor
- Aortic pathology
- Barrett esophagus
- Zollinger-Ellison syndrome
Clinical Features
Mackler’s triad
- Pathognomonic for Boerhaave syndrome
- Chest pain
- Vomiting
- Subcutaneous emphysema
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
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Evaluation
Imaging[1]
- CXR: 90% will have radiographic abnormalities, nonspecific in nature
- Pneumomediastinum
- Abnormal cardiomediastinal contour
- Pneumothorax
- Pleural effusion
- CT chest: may show pneumomediastinum, but will not show perforation
- Esophagram with water soluble contrast for definitive diagnosis
- Emergent endoscopy, but may worsen the tear during insufflation
Management
- Volume resuscitation
- Broad-spectrum IV antibiotics
- Emergent surgical consultation
Disposition
- Admit
See Also
References
- ↑ 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