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Oesophageal rupture

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Oesophageal rupture and perforation

Updated January 2011 by Charles Gomersall

Causes

Spontaneous

  • raised intraoesophageal pressure (eg secondary to vomiting)
  • oesophageal CA
  • peptic ulceration

Traumatic

  • penetrating chest trauma
  • blunt trauma
  • foreign body
  • swallowed caustic agents

Iatrogenic

Instrumentation

  • dilatation
  • oesophagoscopy
  • intubation

Surgery

  • anastamotic leak
  • intraoperative:
    • vagotomy
    • thyroidectomy
    • oesophageal myotomy
    • aortic surgery

Clinical features

  • often produces immediate and often catastrophic clinical features
  • perforation due to direct trauma from endoscope occurs most commonly in cervical region: early signs include neck pain or stiffness, difficulty swallowing, cough and cervical emphysema. Patient may not develop signs of serious illness for several hours due to discontinuity between cervical oesophagus and mediastinum
  • perforation of intrathoracic oesophagus generally results in more rapid progression to acute illness due to quick spread of infection, rapid development of mediastinitis and fluid sequestration
    • chest pain within minutes
    • dyspnoea frequently prominent
    • pleural effusion
    • mid oesophageal perforations (common when secondary to dilatation) associated with spread into right pleural cavity, lower oesophageal perforations (common in spontaneous perforations) associated with spread into left pleural cavity
  • intra-abdominal perforation causes peritonitis, systemic sepsis and epigastric pain within mins-hours

Investigations

  • CXR:
    • pleural effusion
    • pneumomediastinum
  • gastrograffin swallow
  • food particles, pH<6 and ­ amylase in pleural fluid
  • CT may be useful if diagnosis remains in doubt, especially if there is a delay in diagnosis

Management

Three main approaches to management: surgical, endoscopic and conservative. Little evidence to guide choice.

Early presentation (<48h)

  • endoscopic or surgical management. Surgical management preferred in septic patients
  • endoscopic management consists of placing self-expanding metal stent to cover rupture and drainage of any pleural collections
  • surgical management:
    • rupture into pleural space: thoracotomy, resection and pleural/mediastinal drainage (rupture into both pleural spaces) or thoracotomy, hemifundoplication and pleural/mediastinal drainage
    • Intra-abdominal rupture: laparotomy, local repair and drainage

Late presentation (>48h)

  • septic patients: surgical management
  • non-septic: conservative management
    • NG drainage (controversial - may increase gastric reflux)
    • chest drainage on side of perforation
    • broad spectrum antibiotics
    • nil by mouth for at least 10 days, TPN or feeding jejunostomy
    • if patient’s condition deteriorates or fails to improve in 24 h seriously reconsider operative management

Outcome

  • factors associated with poor outcome:
    • poor general condition, especially associated oesophageal CA
    • spontaneous worse than traumatic or instrumental
    • intrathoracic or intra-abdominal
    • >24 h delay in diagnosis and initiation of treatment
  • mortality averages ~15%

Spontaneous rupture

  • most commonly follows forceful vomiting but has been reported following defaecation, childbirth, blunt trauma, fits, heavy lifting and forceful swallowing
  • elevated amylase in pleural fluid strongly suggests diagnosis but its absence does not exclude it. Raised pleural fluid amylase, epigastric pain, nausea and vomiting can also be due to acute pancreatitis
  • Mackler's triad (vomiting, chest pain and cervical emphysema) almost pathognomonic but absent in almost half the cases
  • most spontaneous perforations occur in lower left oesophagus just above diaphragm

Further reading

Sellke FW. Esophageal perforation and mediastinitis. In Rippe JM, Irwin RS, Fink MP, Cerra FB (eds), Intensive Care Medicine, 3rd ed. Little Brown & Co., Boston, 1996, pp 1841-5

de Schipper JP et al. Spontaneous rupture of the oesophagus. Boerhaave's syndrome in 2008. Dig Surg 2009;26:1–6

 


© Charles Gomersall December 1999

 

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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