Oesophageal Perforation

Background

  • Relatively rare (1-3/100,000).
  • Most commonly iatrogenic (up to 70% of all cases)- usually OGD (oesophago-gastro-duodenoscopy)
    • Risk of perforation from this procedure is low (3 in 10,000 or 0.03%)
      • More common (1-5% if the test is also therapeutic)
    • Iatrogenic perforation commonly occurs in the pharynx or distal oesophagus (narrowing)
  • Other causes include trauma (penetrating injuries e.g. knife wounds) and spontaneous perforation (often following violent vomiting- Boerhaave’s syndrome)
    • This commonly occurs just above the diaphragm in the posterolateral wall of the oesophagus
  • Significant morbidity/mortality
    • If treated within 24 hours- mortality of about 25%.  This increases to 65% >24 hours and to 75%+ after 48 hours

Presentation

  • Clinical symptoms/signs depends on the site/size of perforation
    • Cervical region
      • Neck pain, local tenderness
      • Surgical emphysema
    • Thoracic region
      • retrosternal chest pain
      • dysphagia
      • patient may present shocked, short of breath or cyanosed if the pleural space is involved (assuming perforation is traumatic)
      • patient may present with septic shock (mediastinitis)
    • Abdominal region
      • peritonitis/septic shock

Investigation/Diagnosis

  • NB Have a high index of suspicion in patients who have recently had an invasive procedure or violent episode of vomiting
  • Erect CXR
    • Look in particular for:
      • Air under the diaphragm
      • Surgical emphysema (small collections of subcutaneous air-sacs) in the mediastinum, which may extend up to the neck
      • The mediastinum may also be widened
      • If the pleural space is involved- a hydropneumothorax may be seen
  • CT scan (most useful in establishing diagnosis)
  • Barium/water soluble contrast swallow

Management

  • May be managed non-operatively (small/micro-perforations, particularly those in the cervical region)
    • IV fluid, nil by mouth, IV antibiotics/antifungals
  • Larger defects will often require repair, although morbidity is high, and many patients will require an oesophagocutaneous fistula; prolonged mediastinal drainage; antibiotics/antifungals and enteral feeding via a jejunostomy.

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