Esophageal perforation: Difference between revisions
| Line 27: | Line 27: | ||
#*Usually acute and sudden in onset | #*Usually acute and sudden in onset | ||
#*Radiation to the back or to the left shoulder | #*Radiation to the back or to the left shoulder | ||
#Vomiting (+/- shortness of breath) | #[[Vomiting]] (+/- [[shortness of breath]]) | ||
#*In about 25% of the patients | #*In about 25% of the patients | ||
#Subcutaneous emphysema | #[[Subcutaneous emphysema]] | ||
===Other Possible Symptoms=== | ===Other Possible Symptoms=== | ||
*Neck pain | *[[Neck pain]] | ||
**When cervical esophagus is perforated | |||
*Dysphonia, hoarseness, cervical dysphagia | *Dysphonia, hoarseness, cervical dysphagia | ||
*Acute abdominal or epigastric pain | *Acute abdominal or [[epigastric pain]] | ||
**Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melena | **Rarely manifest with hematemesis or other signs of gastrointestinal bleeding, including melena | ||
*Fever is a late sign | *[[Fever]] is a late sign | ||
===Later Signs (Generally within 24-48 Hour)=== | ===Later Signs (Generally within 24-48 Hour)=== | ||
*SIRS | *[[SIRS]] | ||
*Sepsis | *[[Sepsis]] | ||
*Overwhelming bacterial mediastinitis | *Overwhelming [[]bacterial mediastinitis]] | ||
*Multiple organ failure | *Multiple organ failure | ||
*Death | *[[Death]] | ||
==Mackler’s triad== | ==Mackler’s triad== | ||
Revision as of 19:38, 1 November 2023
Background
- Full thickness perforation of the esophagus
- Secondary to sudden increase in esophageal pressure
- Perforation is usually posterolateral
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 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)
Mackler’s triad
- Pathognomonic for Boerhaave syndrome
- Chest pain
- Vomiting
- Subcutaneous emphysema
- Palpable in up to 60% of patients[1]
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
- Pneumomediastinum
- Abnormal cardiomediastinal contour
- Pneumothorax
- Pleural effusion
- 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
- Volume resuscitation
- Broad-spectrum IV antibiotics
- ex. Piperacillin/tazobactam + Vancomycin
- Emergent surgical consultation
Disposition
- Admit (generally to OR for emergent repair)
See Also
External Links
- emDocs - Esophageal Perforation: Pearls and Pitfalls for the Resuscitation Room
- CORE EM - Boerhaave Syndrome
References
- ↑ 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
- ↑ 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