emDOCs Podcast – Episode 62: Esophageal Perforation/Rupture

Today on the emDOCs cast with Brit Long, MD (@long_brit), we cover esophageal rupture and perforation.


Episode 62: Esophageal Perforation/Rupture

 

Background:

  • Full-thickness tear of the mucosal/muscular layers of the esophagus from sudden increase in esophageal pressure
  • Esophagus lacks a serosal layer (more susceptible to perforation)
  • With perforation, gastric contents and bacteria extravasate into the mediastinum => mediastinitis, systemic infection, empyema
  • Mortality rates reach 90% if not diagnosed and treated

 

Causes:

  • Boerhaave Syndrome: spontaneous rupture, defined as “rupture of the esophagus due to forceful emesis”
    • Rapid increase in intraesophageal pressures and opposing negative intrathoracic pressure
    • Accounts for 15% of cases
  • Most common etiology of esophageal rupture is post endoscopy
    • Perforation associated with endoscopy is still very rare
  • Other causes: foreign body or caustic ingestion, trauma, tumor, aortic pathology, infection

 

History and Exam:

  • Must consider in patients with chest/abdominal pain
  • Evaluate for risk factors (prior esophageal pathology and endoscopic procedures)
  • Vomiting classically associated with Boerhaave, but this is just one cause of sudden increase in intraesophageal pressure
    • Others: childbirth, seizure, prolonged coughing/laughing, extreme exertion/weightlifting
  • Mackler’s triad of Boerhaave syndrome: 1) severe vomiting followed by 2) chest pain and 3) subcutaneous emphysema. Present in less than 50%
  • Nausea and vomiting present in less than 20%
  • Pain is most common presenting symptom (70%), but depends on perforation location
  • Other symptoms also depend on location
    • Cervical esophageal perforation – dysphagia and pain with neck flexion; dysphagia is present in 10%
    • Thoracic esophageal perforation – chest, back, and/or epigastric pain; dyspnea in 26%
    • Distal esophageal perforation with leakage into abdominal cavity – peritonitis and radiation of pain to shoulders as a result of diaphragmatic irritation
  • Systemic symptoms occur with severe pain and mediastinal perforation; fever may be delayed (40-50%)
  • Subcutaneous emphysema in the neck and/or chest suggestive, but occurs in less than 60% of patients
    • Hamman’s crunch: crunching sound over the precordium that occurs with each heartbeat with auscultation of the chest
    • Abnormal breath sounds due to pleural effusion or pneumothorax

 

ED Evaluation

  • Labs: Not specific, cannot exclude diagnosis, need imaging
    • World Society for Emergency Surgery (WSES) recommends CBC, electrolytes, creatinine, liver function tests, pH, and lactate in the initial evaluation (Grade 1C recommendation).
    • Inflammatory markers may be elevated
  • Imaging:
    • Chest X-ray abnormal in 90%
      • May see pneumomediastinum and subcutaneous emphysema
      • V sign – air outlining the medial left hemidiaphragm and left lower mediastinal border
      • Later findings include pleural effusion (usually left sided), mediastinal air-fluid levels, free air under the diaphragm, hydrothorax, pneumothorax
    • Definitive imaging: CT chest with IV contrast or CT esophagography
      • CT chest with IV contrast: 92-100% sensitivity; can rule out alternate diagnoses, evaluate for involvement of surrounding structures, guide management
      • If suspicious but CT negative, other tests include diagnostic endoscopy or fluoroscopy using water-based contrast

 

Management:

  • Broad-spectrum intravenous antibiotics, manage symptoms with antiemetics and analgesics, PPI administration, make patient NPO, consult specialists for definitive therapy
  • Specialists include thoracic surgery, interventional radiology, gastroenterology, and critical care
  • Several options available for definitive therapy: direct repair and washout, hybrid approach, non-operative
    • Primary repair with washout: large perforations, overwhelming mediastinal infection, or large infectious collection formation
    • If surgical intervention is necessary but will be delayed and the patient has significant GI material in the pleural cavity with hemodynamic compromise, consider chest tube
    • Hybrid approach: minimally invasive, depends on location of the perforation, underlying pathologies, and clinical status of the patient
      • Example: GI stent placement, IR fluid drainage, admission to ICU
    • Non-operative: patients with early diagnosis and contained leak within the cervical esophagus and/or mediastinum; no abdominal involvement; no signs or symptoms of systemic infection
  • Airway: May need airway management if hemodynamically unstable/respiratory distress or with accumulation of profound amounts of subcutaneous air
    • Caution with NIPPV: the potential increase in transluminal pressure within the esophagus could potentially worsen the tear, as well as increase subcutaneous air, leading to more difficulty in establishing a definitive airway
    • If toxic, respiratory distress, intubation is a good idea
  • NG tube placement:
    • Place with care and speak with GI/surgeons first; increases in intraluminal pressure from eliciting a gag reflex could theoretically worsen the tear
  • Antifungals:
    • Some patients may benefit: history of immunocompromise, esophageal lesions or infections, prolonged proton pump inhibitor use, or other risk factors for fungal infection should receive intravenous antifungal coverage such as fluconazole or caspofungin
    • Discuss with ID and surgical specialists

 

Reference:

  • DeVivo A, Sheng AY, Koyfman A, Long B. High risk and low prevalence diseases: Esophageal perforation. Am J Emerg Med. 2022 Mar;53:29-36.

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