Esophageal perforation: Difference between revisions

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==Background==
==Background==
*Full thickness perforation of the esophagus
*Secondary to sudden increase in esophageal pressure
*Perforation is usually posterolateral
===Causes===
===Causes===
*Iatrogenic
*Iatrogenic (most common)
**Endoscopy
*[[Boerhaave syndrome]]
*[[Boerhaave syndrome]]
*[[Thoracic Trauma]]
*[[Thoracic Trauma]]
**Penetrating
**Penetrating
**Blunt (rare)
**Blunt (rare)
*Caustic ingestion
*[[Caustic ingestion]]
*Foreign body
*[[ingested foreign body|Foreign body]]
**Bone, button battery
**Bone
*Infection (rare)
**Button battery
*[[Infection]] (rare)
*Tumor
*Tumor
*Aortic pathology
*Aortic pathology
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==Clinical Features==
==Clinical Features==
*Mackler’s triad of chest pain, vomiting and subcutaneous emphysema is pathognomonic for the disease
 
==Mackler’s triad==
*Pathognomonic for [[Boerhaave syndrome]]
**[[Chest pain]]
**[[Vomiting]]
**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 localized to chest, neck, abdomen; radiate to back and shoulders
**May be localized to chest, neck, abdomen; radiate to back and shoulders
*Dysphagia
**Occurs suddenly, often after forceful vomiting
*Dyspnea
*[[Dysphagia]]
*Hematemesis
*[[Dyspnea]]
*[[Hematemesis]]
 
===Physical Exam===
===Physical Exam===
*Cervical subcutaenous emphysema
*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
***Mediastinal crunching sound
*May rapidly develop [[sepsis]] due to [[mediastinitis]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Chest Pain DDX}}
{{Chest Pain DDX}}
 
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


==Diagnosis==
==Evaluation==
===Imaging<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>===
===Imaging<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>===
*[[CXR]]: 90% will have radiographic abnormalities
*[[CXR]]: 90% will have radiographic abnormalities, nonspecific in nature
*CT chest: may show pneumomediastinum, but won't show perforation
[[File:Boerhaave.jpg|thumbnail|Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.]]
*Esophagram with water soluble contrast for definitive diagnosis
**[[Pneumomediastinum]]
*Emergent endoscopy, but may worsen the tear during insufflation
**Abnormal cardiomediastinal contour
**[[Pneumothorax]]
**[[Pleural effusion]]
*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==
==Management==
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*Broad-spectrum IV [[antibiotics]]
*Broad-spectrum IV [[antibiotics]]
*Emergent surgical consultation
*Emergent surgical consultation
==Disposition==
*Admit (generally to OR for emergent repair)


==See Also==
==See Also==
*[[Ingested foreign body]]
*[[Esophageal Injury]]
*[[Esophageal Injury]]


==References==
==References==
 
<references/>
[[Category:GI]]
[[Category:GI]]

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