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Esophageal Perforation

posted Jul 30, 2013, 11:08 AM by Purnema Madahar   [ updated Jul 30, 2013, 11:08 AM ]

Today's Monte Daily is brought to you by Nelson Chuang!

Good day, sorry for the delay as I know all of you are anxiously awaiting to read the RAT entry…

Friday we had a case of a 54 year old man who was unfortunate enough to perforate his esophagus via ingestion of a fishbone. Also unfortunate for you guys there are no good reviews out there regarding esophageal perforations-and especially not on fishbones. Fortunate for you guys it was my job to compile what little was out there. Read on. It’s quick.

When people usually hear esophageal perforation they automatically think was this patient retching or did this patient have a procedure done. Who thinks fishbone (except Norman)? Technically, Boerhaave’s is rupture in the sense there is increased intraesophageal pressure. So retching is not the only cause of Boerhaave’s-apparently weightlifting and “childbirthing” are other causes. Most common cause is iatrogenic and typically from an endoscope. Here’s a small breakdown:

Iatrogenic:                                                                          45-75%
Increased intraesophageal pressure:                      5-20%
Traumatic:                                                                           4-10%
Ingestion:                                                                            0-12%
Misc (cancer, infection, aortic dissection):            0-5%

Clinical Presentation:
This is probably the most important part for you guys. As seen in our case, but a problem in general is the overlapping symptoms with other causes of chest pain. Everyone did well prioritizing the most lethal differentials, but esophageal perforation came in at number 12. Shingles was number 4, above aortic dissection. So how does esophageal perforation chest pain present?

Most common complaint will be chest pain (about 70% of cases). Less common but probably more specific complaint is the dysphagia and likely odynophagia. Pain can radiate to the shoulder and back, and in 25% of patients it is followed by vomiting and shortness of breath. When the vomiting and chest pain is accompanied by subcutaneous emphysema, they have earned the Mackler triad-seen in only about maybe 50% of cases. Important to note, bleeding is rare.

The initial injury can present with localized pain but when the luminal contents pour into the mediastinum that’s when these patients complain of diffuse substernal chest pain that is all over. When that turns into mediastinitis that’s when you can expect high fevers, sepsis, and potential cardiopulmonary collapse. Mortality is, needless to say, high.

Diagnostic Workup
Patients will usually have leukocytosis by the time they present. If you are on the floors, patients come packaged with a complimentary chest film; however, as an outpatient physician you should order it. The CXR can reveal pleural effusions, pneumomediastinum, subcutaneous emphysema, hydrothorax, and pneumothorax. In our patient, all he had was pleural effusions, which can either be erosion of gut contents through the mediastinal pleura into the lung pleura or a sympathetic reflex without erosion. If you jump to the CT scan, it can show oral contrast leak, mediastinitis, as well as better resolution of the same findings on CXR. If clinical suspicion is high (ie “doctor I ate a fishbone and it definitely perforated my esophagus”), then you would probably want EGD. However, you can’t scope them in the acute setting, but you can have them drink water-soluble gastrograffin. Only use Barium if the gastrograffin contrast esophagogram is negative for leak as you do not want to cause barium-related inflammation of the mediastinum. Lastly, EGD is your best test that can directly visualize the injury. Bottom line here is, if you diagnose it or if your suspicion is high, call surgery!

Esophageal perforation management basically falls into emergent or conservative management. Emergent means to the OR. Conservative management means the perforation is contained (no leak on imaging) and the patient is not hemodynamically unstable. History can be important here again, because iatrogenic injuries caused by EGD can usually be managed conservatively. Our patient kind of received both due to difficulty in establishing diagnosis. Whether they are or not going to the OR, logically, these patients should be: NPO, on broad spectrum antibiotics for anaerobe and Gram positive/negative aerobes, NG tube, and they may need percutaneous drains if necessary. Again, call your Surgery and GI consults.

Take home:
1. If things aren’t making sense, especially after negative tests or incongruous results, please go back to the bedside and get more information from the patient.

2. Retching and endoscopes are not the only causes esophageal perforation.

3. Esophageal perforation es un emergencia!