Surgery was urgently consulted and the patient taken to the OR where he underwent primary repair of a distal esophageal perforation and removal of an impacted bezoar with EGD. The patient did well post-operatively and was discharged in stable condition on hospital day 4.
Esophageal Perforation - Rapid Fire
- Most common cause of esophageal perforation --> endoscopy
- Other causes of esophageal perforation:
- foreign body ingestion
- caustic substance ingestion
- severe esophagitis
- carcinoma
- direct injury related to blunt or penetrating trauma
- Pathophysiology of Boerhaave syndrome --> rapid increase in intraesophageal pressure related to forceful vomiting
- More than 90% of spontaneous esophageal ruptures occur in the distal esophagus
- Mackler's triad is pathognomonic for spontaneous esophageal rupture
- subcutaneous emphysema
- chest pain
- vomiting
- Pain associated with distal esophageal rupture often radiates to the back
- Hamman's sign or crunch = "crunching" sound auscultated over chest, pathognomonic for mediastinal emphysema
- Diagnose with esophagram and/or CT chest
- Misdiagnosis occurs in half of patients because of the broad differential of chest and abdominal pain
- Management
- broad-spectrum antibiotics
- NPO
- urgent surgical consult
- growing body of evidence suggests small, contained iatrogenic perforations can be managed conservatively without surgery
- Outcome Thoracic esophageal perforations. Am Surg. 76:1355-1362 2010)
- 97% survival rate with treatment in first 24 hours
- 89% with treatment after 24 hours
References:
Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 89: Esophagus, Stomach, and Duodenum by Jamie M. Hess and Mark J. Lowell
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