Esophageal Perforation

Etiology

  • Esophagogastroduodenoscopy (EGD): most common etiology
  • Boerhaave’s Syndrome: emetogenic esophageal rupture
  • Sengstaken-Blakemore Tube
  • Esophageal Foreign Body
  • Esophageal Cancer (see Esophageal Cancer, [[Esophageal Cancer]])

Physiology

  • Esophageal Perforation with Acute Mediastinitis
    • Most cases have subsequent pleural space infection

Diagnosis

  • Pleural Fluid
    • pH: decreased (often <7.0)
    • Cholesterol: elevated >55-60 mg/dL (seen in all exudates)
    • Pleural Fluid Amylase: elevated
    • Pleural/Serum Cholesterol Ratio: elevated (elevated ratio is seen in all exudates)
    • Cell Count/Differential: elevated WBC with PMN-predominance
    • Cytology: meat (muscle) or vegetable matter may be seen
  • CXR/Chest CT Patterns: 90% of cases have abnormal CXR
    • Left Pleural Effusion: usual finding
    • Mediastinal or Subcutaneous Emphysema
    • Infiltrates
    • Pneumoperitoneum: seen in some cases
  • Esophogram: use Meglumine Diatrizoate (Gastrografin)
    • Usually diagnostic: demonstrates leak into left pleural space
    • If negative, do Barium esophagram
  • ABG: metabolic acidosis (due to acute mediastinitis with sepsis)
  • Esophagogastroduodenoscopy (EGD): low sensitivity
    • May enlarge perforation, as well

Clinical Manifestations

Cardiovascular Manifestations

  • Chest Pain (see Chest Pain, [[Chest Pain]])
  • Mediastinal Crunch

Pulmonary Manifestations

Other Manifestations


Treatment

  • Surgical Repair: usually required early
  • Medical Management: may be indicated for clinically stable cases, instrumentation-associated cases with early or late discovery and good tolerance of perforation, and well-contained perforations (with containment in loculated pleural space/mediastinum: no SQ emphysema, PTX, or pneumoperitoneum)

Prognosis

  • Mortality: 22-63% mortality if detected within first 24 hrs (higher mortality with later detection)

References

  • xxxx