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 | **Bone | ||
*Infection (rare) | **Button battery | ||
*[[Infection]] (rare) | |||
*Tumor | *Tumor | ||
*Aortic pathology | *Aortic pathology | ||
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==Clinical Features== | ==Clinical Features== | ||
==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 | *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== | ||
{{ | {{Chest Pain DDX}} | ||
{{Thoracic trauma DDX}} | {{Thoracic trauma DDX}} | ||
== | ==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 | ||
* | [[File:Boerhaave.jpg|thumbnail|Mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery.]] | ||
*Esophagram | **[[Pneumomediastinum]] | ||
*Emergent endoscopy | **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
- 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
- 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
- Volume resuscitation
- Broad-spectrum IV antibiotics
- Emergent surgical consultation
Disposition
- Admit (generally to OR for emergent repair)
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