Esophageal Rupture

Esophageal Rupture
Presentation by: Erin M. Will
Overview

* Esophageal rupture is rare
o Roughly 300 cases reported per year
o The diagnosis is commonly missed/delayed
* Mortality is high
o Most lethal GI perforation
o Mortality falls with early dx/intervention
* Survival depends on rapid dx and surgery
o Within 24 hours of rupture: 70-75% survival
o Within 25-48 hours: 35-50% survival
o Beyond 48 hours: 10% survival

Etiology of Esophageal Rupture

* Traumatic Causes (MORE COMMON)1,2:
o Endoscopy or dilation procedures
+ Stent placement most common cause (up to 25% cases)
o Vomiting or severe straining
o Stab wounds / penetrating trauma
o Blunt chest trauma (rarely)
* Non-Traumatic Causes (LESS COMMON)1,2:
o Neoplasm / Ulceration of esophageal wall
o Ingestion of caustic materials

Demographics
* Spontaneous rupture:
o Middle-aged men
o Alcoholics
* Hx of recent esophageal instrumentation
* Chest Trauma
o Penetrating > Blunt

Anatomy

* Esophagus lacks serosa
o More likely to rupture
* Site of rupture:
o More commonly on left side
o Due to instrumentation: distal esophagus
o Spontaneous: posterolateral esophagus
* Tears are usually longitudinal

Pathophysiology

* Air, Saliva, and Gastric contents released
o mediastinitis
o pneumomediastinum
o empyema
o can progress to sepsis, shock, resp failure
Presentation

* Pain
o lower anterior chest / upper abdomen
o may radiate to left shoulder / back
* Vomiting >> Hematemesis
o hematemesis: think Mallory-Weiss/varices
* Dyspnea
* Cough (precipitated by swallowing)

On Exam

* Subcutaneous Emphysema
* Fever
* Tachycardia
* Tachypnea
* Cyanosis
* Upper Abdominal Rigidity
* Pneumothorax/Hydrothorax
* Respiratory Failure
* Sepsis
* Shock

Initial Imaging: X-ray

* PA and Lateral chest films
o Look for:
+ Hydrothorax (L side > R side)
+ Pneumothorax
+ Hydropneumothorax
+ Pneumomediastinum
+ SubQ emphysema
+ Mediastinal widening
+ Pleural Effusion (L side > R side)
Hydrothorax
Initial Imaging: X-ray
Subdiaphragmatic Air
Interventional Imaging
Gastrografin extravasation
CT scan
Pneumomediastinum
What to do next
Indications for conservative mgmt
What to do next

* Early surgical intervention reduces mortality rate: 1st 24 hours!
Indications for surgery

* Sepsis
* Respiratory Failure
* Shock
* Contamination of mediastinum
* Associated pneumothorax
Resources

Esophageal Rupture.ppt