Oesophageal perforation
- Management and outcome depends on time from injury to diagnosis
- 'Early' injuries are identified within 24 hours
- 'Late' injuries are identified later than 24 hours
Aetiology
- Endoscopic intubation
- OGD
- Bouginage
- Pneumatic dilatation
- Sclerotherapy of oesophageal varices
- Endoscopic prostheses
- Traumatic intubation
- Perioesophageal surgery
- Trauma
- Penetrating
- Foreign body
- Caustic ingestion
- Barotrauma
- Tumours
- Infections
Boerhaave's Syndrome
- Post-emetic rupture of the oesophagus
- First described by Herman Boerhaave in 1723
- His patient was Baron Jan von Wassenaer, Grand Admiral of the Dutch Fleet
- Vomited after a meal and developed left-sided chest pain
- Died 18 hours later
- At post mortem the following were found
- A tear of the left posterior wall of the oesophagus
- 5 cm above the diaphragm
- Surgical emphysema
- Food in the left pleural space
Clinical features
- Oesophageal rupture occurs
- After 0.1% of standard endoscopies
- After 2% of oesophageal dilatation
- Diagnosis requires high index of suspicion
- Typical symptoms include chest pain, and dysphagia
- Signs include pyrexia, tachycardia, hypotension, tachypnoea
- Subcutaneous emphysema may be present
- Undiagnosed systemic sepsis rapidly develops
- Death often occurs with 48 hours
- Chest x-ray may show pleural air / fluid level and mediastinal emphysema
- Diagnosis can be confirmed by water-soluble contrast swallow
Pictures provided by Livio Di Mascio, Royal Free Hospital, London
Management
Conservative management
- Conservative management may be appropriate for:
- Small perforations without systemic upset
- Small contained thoracic leaks
- Requires
- Nil by mouth
- Antibiotics
- Intravenous hydration
- Failure of conservative management will need surgery
Operative management
- Management principals for thoracic perforations include:
- Control oesophageal leak
- Eradicate mediastinal / pleural sepsis
- Re-expand lung
- Prevent gastric reflux
- Nutritional and pulmonary support
- Antibiotics
- Post-operative drainage of residual septic foci
- Methods of treatment include:
- Primary closure with buttress or patch
- Exclusion and diversion
- T-tube fistula
- Thoracic drainage an irrigation
- Resection
- Decompression gastrostomy and feeding jejunostomy
- If operated on within 24 hours mortality is 5-10%
- If operation delayed more than 48 hours mortality is more than 50%
Bibliography
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