EM@3AM – Esophageal Perforation

Author: Erica Simon, DO, MHA (@E_M_Simon, EMS Fellow, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 39-year-old male, with a previous medical history of achalasia, presents to the ED for progressively worsening chest pain, which radiates to his right shoulder. The male reports his pain as constant, severe (10/10), and associated with dyspnea, and non-bloody, non-bilious emesis (3 episodes). ROS is remarkable for esophageal dilation performed 36 hours prior to arrival.

Triage VS: BP 101/71, HR 124, T 102.4 F oral, RR 24, SpO2 97% on room air.

Pertinent physical examination findings:
CV: S1, S2, tachycardia, regular rhythm
Lungs: Decreased breath sounds R base
Abdomen: Soft NT, ND, absent guarding and rebound

EKG: Sinus tachycardia, axis WNL, normal intervals, no acute ST-T wave changes

CXR: Pneumomediastinum, R pleural effusion

What’s the next step in your evaluation and treatment?

Answer: Esophageal Perforation1-3

  • Epidemiology: Most frequent etiology: iatrogenic injury following upper endoscopy and transesophageal echo (TEE) (60%).1 May also occur secondary to retching (Booerhave’s syndrome), caustic ingestion, trauma, foreign body, or malignancy. Despite advances in imaging technology and techniques for surgical repair, associated mortality is reported as 40%.1
  • Risk Factors: Conditions pre-disposing to a requirement for endoscopy, biopsy, or dilation: reflux esophagitis, hiatal hernia, strictures, achalasia.
  • Clinical Presentation: Patients may report pain localized to the chest/midepigastrum or shoulder; abdominal pain, nausea, dysphagia, dyspnea, and/or fever.
  • Evaluation and Treatment:2,3
    • Assess the ABCs and obtain VS.
      • It is not uncommon for patients to present with SIRS/sepsis secondary to mediastinitis.1
    • Perform a thorough H&P:1,2
      • Question specifically regarding recent TEE or endoscopy.
      • Physical Examination:
        • Cardiac: possible Hamman’s crunch.
        • Abdomen: may encounter guarding or rigidity (intra-abdominal rupture).
    •  Laboratory evaluation: CBC: leukocytosis common.
    •  Imaging:
      • CXR: may demonstrate pneumomediastinum, pneumothorax, subcutaneous emphysema, or pleural effusion.
      • Gastrograffin esophagram (ED test of choice): esophageal irregularity or extravasation of contrast.
        • Patients in whom initial imaging is negative, but signs/symptoms are highly suggestive of perforation => consultation.
          • Repeat imaging in 4-6 hours recommended.3
          • Endoscopy should be considered.3
    •  Treatment:2,3
      • Initiate broad-spectrum antibiotics:
        • Piperacillin/tazobactam (3.375 g IV) or
        • Cefotaxime (2 g IV) or ceftriaxone (2 g IV) + clindamycin (600 mg IV) or metronidazole (15mg/kg IV, then 7.5 mg/kg IV q 6 hr; max 1 g/dose).2
      • Fluid resuscitation as appropriate.
      • Disposition => all patients require hospitalization.
  • Pearls:
    • Individuals with esophageal perforation may be managed operatively or non-operatively according to: the patient’s hemodynamic status, the location and size of the defect, whether or not the perforation is “free” or “contained,” and the degree of contamination.
    • Intra-abdominal esophageal perforation often manifests as peritonitis.1



  1. Maxwell R, Reynolds J. The Management of Esophageal Perforation. In Current Surgical Therapy. Philadelphia, PA, Elsevier. 2017.
  2. Sokolosky M. Esophageal Emergencies. In Tintinalli’s Emergency Medicine Manual. 8th ed. New York, NY. McGraw-Hill. 2018.
  3. Soreide J, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011; 19-66.


For Additional Reading:


Mediastinitis: ED-Focused Basics:

Mediastinitis: ED-focused basics

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