eMedicine Specialties > Radiology > Gastrointestinal

Esophagus, Tear

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK
Coauthor(s): Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Contributor Information and Disclosures

Updated: Oct 15, 2008

Introduction

Background

Esophageal tear is defined as a breach of the esophageal wall resulting from a mucosal tear, perforation, or rupture. Tears of the esophagus are life-threatening conditions that require prompt diagnosis and emergency treatment. The most common causes of esophageal tear, perforation, and hematoma are iatrogenic factors.^1,2,3

Esophageal perforations allow the upper gastrointestinal (GI) contents to egress from the esophageal lumen into the soft tissues of the neck, the mediastinum and pleural space, the peritoneal cavity, and other possible sites (depending on the location of the injury). If esophagus tears remain untreated, then cervical soft tissue infections, mediastinitis, pleuritis, or peritonitis will develop, followed by systemic sepsis and death. Esophageal perforations or tears almost always require surgical correction; however, a small and contained esophageal tear may occasionally be managed expectantly.^1,4

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center.

Pathophysiology

Esophageal perforations, Mallory-Weiss tears, and esophageal hematomas may result from traumatic injury to the esophagus following instrumentation, such as after gastric lavage or upper GI endoscopy. Recent increases in the use of diagnostic and therapeutic endoscopy and esophageal surgery have made endoscopic instrumentation the most common cause of esophageal rupture.^1,2,3,5,6

In more than 90% of cases, esophageal perforation occurs in the lower third of the esophagus. A tear 0.6-8.9 cm long has a predilection for the left posterolateral region (90%). This predilection for left-sided perforations may be caused by a lack of adjacent supporting structures, thinning of the musculature in the lower esophagus, and anterior angulation of the esophagus at the left diaphragmatic crus. Tears of the esophagus usually extend superiorly. Perforation of the esophagus resulting from instrumentation or trauma does not appear to have a specific site predilection.^7,8

Types of esophageal injuries

Esophageal perforations can be classified into 2 types: ruptures and esophageal mucosal tears.

Esophageal rupture occurs because, unlike the rest of the alimentary tract, the esophagus lacks a serosal layer, which usually contains collagen and elastic fibers. The esophageal wall is comparatively weaker than other sections of the alimentary tract and may rupture at a lower intraluminal pressure. Vomiting is usually the precipitating factor for spontaneous esophageal rupture. Esophageal rupture is a life-threatening injury. Prompt diagnosis and treatment provide the best likelihood for survival; however, delayed diagnosis is common, resulting in significant morbidity and mortality.^1,7,8

Esophageal tears are estimated to occur in 1% of patients with blunt trauma, but they are far more common with penetrating or iatrogenic trauma. Esophageal rupture carries a high mortality rate secondary to rapidly developing mediastinitis. Survival improves dramatically if the esophageal injury is recognized and treated within 24 hours of its occurrence.^{1,2,4,9,10,11,12}

About 82% of esophageal tears caused by blunt trauma occur in the cervical and upper thoracic esophagus. It has been postulated that compression of the esophagus between the sternum and vertebral column is the mechanism of injury. Tears may also occur in the distal esophagus just above the gastroesophageal junction along the left posterolateral wall. The mechanism of injury in this setting is probably similar to spontaneous rupture in Boerhaave syndrome, in which esophageal pressures rise against a closed glottis.^11,13

Boerhaave syndrome

Boerhaave published a case in 1724 of esophageal rupture associated with forceful retching and vomiting; this clinical syndrome bears his name today. It is one of the most famous anecdotes in the annals of medical history.

Hermann Boerhaave, a Dutch doctor, attended a gluttonous patient, the Baron van Wassenaer, the Grand Admiral of the Dutch Fleet. The admiral was a habitual user of emetics, which he self-administered to purge himself after large meals. In what was to be a fatal move, van Wassenaer induced vomiting after dining on goose. He was suddenly stricken with severe, intense pain localized to the upper abdomen. Crying out in agony, he expressed certainty of his own impending death. In less than 24 hours, he was dead. Boerhaave performed an autopsy and discovered a tear of the lower esophagus associated with spillage of the gastric contents into both pleural spaces. On opening the thorax, Boerhaave was struck by the aroma of goose flesh. The admiral had a transverse tear, a rare condition.¹⁴

Mallory-Weiss tear

In 1929, Kenneth Mallory and Soma Weiss first described a syndrome characterized by esophageal bleeding from a mucosal tear in the esophagus as a result of forceful vomiting or retching. The initial description was associated with alcoholic bingeing; however, with the advent of endoscopy, Mallory-Weiss tears have been diagnosed in many patients with no history of alcohol intake.¹⁵

Any disorder that initiates vomiting may also result in the development of a Mallory-Weiss tear, which occurs as a linear laceration at the gastroesophageal junction. At this point, the esophagus and stomach are cylindrical; the cylindrical shape makes longitudinal tears occur more easily than circumferential tears.^3,7

Two mechanisms are postulated to play a part in the development of Mallory-Weiss tears:

1. A rapid increase in intragastric pressure that increases forceful fluid ejection through the esophagus.
2. A significant change in transgastric pressure (ie, a difference in pressure across the gastric wall) caused by negative intrathoracic pressure and positive intragastric pressure, which leads to distortion of the gastric cardia and results in a gastric or esophageal tear.

Because of these factors, Mallory-Weiss tears occur more commonly in patients with hiatal hernias.³

Although the tear of the esophagus typically occurs after repeated episodes of vomiting or retching, it may occur after a single incident. Most of the written reports of these tears relate to adults; however, Mallory-Weiss tears also occur in children.

Han and Tishler described 5 patients with perforations of the abdominal portion of the esophagus. Perforation occurred into the retroperitoneal space in the 2 patients with a tear of the abdominal segment alone. The other 3 patients had tears that extended above the diaphragm. Of those 3, perforation involved both the thorax and lesser sac in 1 patient and into both the thorax and retroperitoneal space in the other 2 patients. The treatment and clinical manifestations in these patients is different from those in patients with more common intrathoracic perforations.¹⁶

Frequency

United States

Esophageal tears are estimated to occur in 1% of patients with blunt trauma, but they are far more common with penetrating or iatrogenic trauma. Esophageal rupture has a high mortality rate secondary to rapidly developing mediastinitis. Survival improves dramatically if the esophageal injury is recognized and treated within 24 hours of its occurrence. Boerhaave syndrome is rare, with an estimated incidence of only 1 case in more than 6000 patients. It accounts for 15% of cases of esophageal rupture or perforation.^{1,2,4,9,10,11,12,17,18}

International

There are no data to suggest that the international frequency of esophageal tears is different from that in the United States.

Mortality/Morbidity

Even with prompt therapy, the mortality rate is high, varying from 30-50%. If there is a delay in diagnosis, the mortality rate exceeds 90%. Mortality rates from perforation caused by instrumentation are lower than they are for other causes (15-20%), although they are clearly still notable.

Vertebral osteomyelitis has been reported in association with penetrating and blunt traumatic esophageal rupture.¹¹

• The major complication in a Mallory-Weiss tear is bleeding. Patients present with variable bleeding, which can range from a few specks or streaks of blood mixed with mucus to copious amounts of fresh red blood. In adults, shock occurs in up to 20% of patients bleeding from Mallory-Weiss tears who present to emergency departments, while up to 45% of patients develop postural hypotension. In contrast, children rarely have hemodynamic instability.^3,19
• Iatrogenic perforation and spontaneous rupture have the same poor prognosis. Nonsurgical treatment is rarely indicated. Esophagectomy is a good option in the case of a nonsuturable esophagus or delayed surgery.^20,21
• Graeber et al conducted a review to determine whether patients with Boerhaave syndrome have higher morbidity and mortality rates than patients with endoscopic iatrogenic esophageal perforations. They reviewed the records of 3 medical centers from 1960 to 1985 and identified 11 patients with Boerhaave syndrome (which they called group B) and 19 patients with iatrogenic perforations (which they called group E). Four cases in group B and 4 in group E were diagnosed more than 24 hours after perforation. Nine patients were treated surgically; of these, 1 died. Two group B patients who were treated conservatively recovered. Of the 19 patients in group E, 15 were treated surgically and 4 were treated medically. In group E, 3 patients died; 1 had been treated surgically, and the other 2 were conservatively treated. These results suggest that the mortality rates between the 2 groups of patients are essentially the same as long as the diagnosis and treatment occur early.¹⁷

Race

No information about racial predilection is available.

Sex

• Boerhaave disease is generally associated with vomiting and customarily occurs after drinking and eating binges. It is more commonly observed in men than in women.
• Mallory-Weiss tears occur with equal frequency in the 2 sexes in adults, but they have different causes. In women of childbearing age, the most common cause of Mallory-Weiss lacerations is hyperemesis gravidarum (severe persistent nausea and vomiting), which usually occurs in the first trimester. Any female adolescent presenting with a Mallory-Weiss tear should be evaluated for pregnancy.³

Age

• Spontaneous esophageal perforation usually is observed in patients aged 40-60 years. Iatrogenic perforation is generally associated with a preexisting pathology; therefore, it is a disease of the fifth and later decades of life.
• Boerhaave syndrome is rare in younger patients. Isolated case reports have documented its occurrence in children.
• Mallory-Weiss tears usually occur in the fifth and sixth decades of life. In children, tears are more commonly observed in older children and adolescents, secondary to the increased intragastric and transgastric pressures that develop at an older age.

Anatomy

The esophagus extends from the cricopharyngeal muscle in the pharynx (15-18 cm from the incisor teeth) to the gastroesophageal junction (at the level of the T11/T12 vertebrae), and it is about 25 cm long.

Anatomically, the esophagus can be subdivided into 4 parts:

1. The cervical esophagus extends from the lower border of the cricoid cartilage to the suprasternal notch.
2. The upper thoracic esophagus extends from the suprasternal notch to the tracheal bifurcation.
3. The midthoracic esophagus extends from the tracheal bifurcation to just above the gastroesophageal junction.
4. The lower thoracic and abdominal esophagus usually represents the gastroesophageal junction. This subdivision is important clinically from both the endoscopic and imaging points of view.

Normally, 2 areas of high pressure are present at rest: the upper esophageal sphincter at the cricopharyngeus muscle, and the lower esophageal sphincter at 2-4 cm proximal to the esophagogastric junction at the level of the diaphragm. The tone of the lower esophageal sphincter is affected by gastrin, acetylcholine, and serotonin, but not by vagotomy.

The arterial blood supply of the cervical esophagus is derived from the inferior thyroid artery, whereas the upper thoracic-bronchial and intercostal arteries, lower thoracic-aortic branches, and abdominal left gastric and inferior phrenic arteries supply the rest of the esophagus. The draining veins form an extensive submucosal plexus that communicates with the periesophageal veins, flowing into the inferior thyroid, azygous, and gastric veins. The lower esophagus is an important site of portosystemic anastomoses, which accounts for it's being the most common site for esophageal varices in portal hypertension.

Lymphatic drainage from the esophagus is provided by freely anastomosing networks of lymph vessels, which can facilitate lengthwise tumor dissemination. The upper third drains into the cervical nodes, the middle third drains into the paraesophageal and paratracheal mediastinal nodes, and the lower third drains into nodes around the aorta and celiac axis.

Imaging can show normal points of narrowing at the level of the cricoid cartilage, aortic arch, anterior crossing of the left main bronchus and the left atrium, and diaphragm. On conventional chest radiographs, the right wall of the normal upper intrathoracic esophagus can often be seen as a shallow S -shaped line extending from the lung apex to the azygos arch. Air is often present within the esophagus, but when air is absent, the right wall of the esophagus is seen as a pleuroesophageal line or stripe. Inferior to the azygos arch, the right wall of the esophagus is in contact with the lower lobe of the right lung and the azygos vein as it ascends toward the arch. This part of the lung has been called the azygoesophageal line.

The configuration of the azygos arch has considerable anatomic variation, which is reflected in the shape of the superior part of the azygoesophageal line. The configuration of the upper few centimeters of the azygoesophageal line is always straight or concave toward the lung. In rare cases, this line is convex, suggesting a subcarinal mass. The line is usually of different configuration and convex in children, particularly children younger than 3 years. In healthy people, the azygoesophageal line can usually be traced inferiorly to the posterior costophrenic angle.

On occasion, the left lung may make contact with the esophageal wall, outlining the esophagus from both the right and the left. The presence of air in the lumen of the esophagus may allow for measurement of the esophageal wall thickness and comparison of wall thickness on the right and left sides. The most common site for air trapped in the esophageal lumen is just inferior to the aortic arch impression.

The normal esophagus is visible on all computed tomography (CT) scans and magnetic resonance imaging (MRI) sections from the neck down to esophageal hiatus. In the presence of sufficient mediastinal fat, the whole circumference of the esophagus is well visualized, and the presence of air in the lumen depicts the uniform thickness of the esophageal wall. When no air is present in the esophagus, it appears as an oval-to-round mass in the posterior mediastinum. The esophagus has signal intensity similar to that of muscle on T1-weighted MRI scans, but it is hyperintense relative to muscle on T2-weighted images.

Presentation

Clinical presentation

The clinical presentation of esophageal tears/rupture includes hematemesis, chest pain, dysphagia, odynophagia, and rapid onset of sepsis, fever, tachycardia, hypotension, and shock. Patients often complain of sudden, sharp epigastric pain radiating to the interscapular area. Dyspnea, cyanosis, and shock are late symptoms.²²

Causes

Iatrogenic perforations account for approximately 55% of esophageal perforations. In a large case series of patients undergoing esophagoscopy, the incidence of perforations was 1.7% (17 cases in 1011 procedures). Of these 17 cases, tumors were found in 8 and achalasia was found in 4; the remaining 5 had strictures or an esophageal anastomosis. The generally accepted complication rates are from 2-6% after pneumatic dilatation for achalasia.^3,17,20

Foreign bodies or traumatic perforations cause all other cases of esophageal perforation. Esophageal rupture secondary to blunt external trauma is very rare, with few cases reported in world literature. Closed chest trauma account for 10% of esophageal perforations, and retained foreign bodies account for 14% of esophageal perforations.^17,20,23,24

Mallory-Weiss tears are the cause for approximately 10-15% of all episodes of hematemesis in adults; however, these tears occur much less commonly in children (<5% of all upper GI bleeding episodes).

Esophageal rupture during balloon dilation for esophageal stricture

Kang et al reviewed the prevalence and clinical importance of esophageal rupture during balloon dilation for treatment of esophageal stricture. They reviewed the case records of 96 consecutive patients of fluoroscopically guided esophageal balloon dilation for esophageal strictures.

The authors classified esophageal rupture into 3 types: intramural (type 1), transmural (type 2), and transmural with mediastinal leakage (type 3). Each patient underwent between 1 and 7 procedures; the patients underwent a total of 191 procedures. Esophageal rupture was reported in 20 of the patients (21%), and all were detected immediately after the procedure; 8 patients had a type 1 rupture, 11 patients had type 2, and type 3 was detected in 1 patient.

Of the patients with esophageal tears, 16 were treated with fasting, parenteral alimentation, and courses of antibiotics. The remaining patients were treated either surgically or with stent placement; no deaths occurred as a result of treatment. A substantial number of patients who developed type 1 rupture had associated clinical symptoms, such as pain and fever, but responded to conservative management and were therefore included as having complications of esophageal balloon dilation.²⁵

Preferred Examination

Conventional radiographs are generally used in the initial assessment of patients with suspected esophageal perforation; this is followed by an oral contrast-enhanced examination, which can be critical in determining the presence and precise location of an esophageal perforation.

Endoscopy is safe and is extremely useful, particularly if an esophageal tear is suspected. Most signs seen on conventional radiographs are better depicted on CT scans.

The use of MRI scanning and ultrasonography is anecdotal; and at the present time, these studies have little if any role in the diagnosis of esophageal perforation.

Superselective left gastric angiography can be performed as a prelude to transcatheter embolization of Mallory-Weiss tears.¹⁹

Limitations of Techniques

Conventional radiographs may be normal in up to 10% of patients with esophageal perforations. Endoscopy, oral contrast-enhanced studies, and angiography are invasive procedures.

Many conditions can result in mediastinal fluid, esophageal thickening, mediastinitis, and extraluminal air within the mediastinum, all of which provide a potential for misdiagnosis. The angiographic diagnosis of upper GI bleeding has several pitfalls.

Differential Diagnoses

Myocardial Infarct, Acute

Other Problems to Be Considered

Pulmonary embolism
Spontaneous splenic rupture
Esophageal, gastric, and duodenal perforations

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