Esophageal perforation: Difference between revisions

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*Full thickness perforation of the esophagus
*Full thickness perforation of the esophagus
*Secondary to sudden increase in esophageal pressure
*Secondary to sudden increase in esophageal pressure
*Perforation is usually posterolateral
   
   
===Causes===
===Causes===
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**Penetrating
**Penetrating
**Blunt (rare)
**Blunt (rare)
*Caustic ingestion
*[[Caustic ingestion]]
*Foreign body
*[[ingested foreign body|Foreign body]]
**Bone
**Bone
**Button battery
**Button battery
*Infection (rare)
*[[Infection]] (rare)
*Tumor
*Tumor
*Aortic pathology
*Aortic pathology
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==Mackler’s triad==
==Mackler’s triad==
*Pathognomonic for Boerhaave syndrome
*Pathognomonic for [[Boerhaave syndrome]]
**Chest pain
**[[Chest pain]]
**Vomiting
**[[Vomiting]]
**Subcutaneous emphysema
**Subcutaneous emphysema


===History===
===History===
*Pain
*[[chest pain|Pain]]
**Acute, severe, unrelenting, diffuse
**Acute, severe, unrelenting, diffuse
**May be worse on neck flexion or with swallowing
**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, often after forceful vomiting
**Occurs suddenly, often after forceful vomiting
*Dysphagia
*[[Dysphagia]]
*Dyspnea
*[[Dyspnea]]
*Hematemesis
*[[Hematemesis]]


===Physical Exam===
===Physical Exam===
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**Hamman's sign  
**Hamman's sign  
***Mediastinal crunching sound
***Mediastinal crunching sound
*May rapidly develop sepsis due to mediastinitis
*May rapidly develop [[sepsis]] due to [[mediastinitis]]


==Differential Diagnosis==
==Differential Diagnosis==
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*[[CXR]]: 90% will have radiographic abnormalities, nonspecific in nature
*[[CXR]]: 90% will have radiographic abnormalities, nonspecific in nature
[[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.]]
**Pneumomediastinum
**[[Pneumomediastinum]]
**Abnormal cardiomediastinal contour
**Abnormal cardiomediastinal contour
**Pneumothorax
**[[Pneumothorax]]
**Pleural effusion
**[[Pleural effusion]]
*Esophagram
*Esophagram
**Water soluble contrast
**Water soluble contrast

Revision as of 20:37, 29 September 2019

Background

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

Causes

Clinical Features

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[1]

  • CXR: 90% will have radiographic abnormalities, nonspecific in nature
Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.
  • Esophagram
    • Water soluble contrast
    • 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

References

  1. 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