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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

Pneumomediastinum due to oesophageal perforation

Thoracic CT showing an oesophageal perforation

Contrast study confirming an oesophageal perforation

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

Chan M F.  Complications of upper gastrointestinal endoscopy.  Gastrointest Clin N Am 1996;  6:  287-303

Janjua K J.  Boerhaave's syndrome.  Postgrad Med J 1997;  73:  265-270.

Mamun M.  Spontaneous oesophageal perforation:  long known but still not easy to diagnoses.  Hosp Med 1998;  58:  969-969.

Reeder L B,  DeFilippi V J,  Ferguson M K.  Current results of therapy for esophageal perforation.  Am J Surg 1995;  169:  615-617.

 

 
 

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