eMedicine Specialties > Thoracic Surgery > Trauma

Esophageal Rupture: Workup

Author: Dale K Mueller, MD, Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois at Peoria; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC
Coauthor(s): Yogesh Govil, MD, MRCP, Consulting Staff, Department of Internal Medicine, Division of Gastroenterology, Crozer-Chester Medical Center; Thomas E Kowalski, MD, Assistant Professor, Department of Medicine, Director, Gastrointestinal Endoscopy Unit, Thomas Jefferson University, Consulting Staff, Thomas Jefferson University Hospital; Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Contributor Information and Disclosures

Updated: Sep 5, 2008

Workup

Laboratory Studies

  • Diagnosis depends on a high index of clinical awareness and relies on confirmatory radiographic findings. However, order lab tests to establish baselines and to help with follow-up care.
  • Complete blood count (CBC): Evidence of leukocytosis is commonplace for almost all esophageal perforations.
  • pH level: Esophageal perforations with penetrance into the pleural cavity have pH levels less than 7.2.

Imaging Studies

  • Although findings may not include significant results if taken early, order urgent posteroanterior and lateral chest and upright abdominal radiographs (diagnostic in 90% of cases) to look for the following conditions:
    • Hydrothorax (usually on the left)
    • Hydropneumothorax
    • Pneumothorax
    • Pneumomediastinum
    • Subcutaneous emphysema
    • Mediastinal widening without emphysema
    • Subdiaphragmatic air
    • Pleural effusions (These are more common on the left but can occur bilaterally and, rarely, only of the right.)
  • Gastrografin (water-soluble contrast) and/or barium esophagram following plain radiography may be performed to look for extravasation of contrast and location and extent of rupture/tear. Twenty-two percent of patients considered to have a strong likelihood of esophageal perforation whose water-soluble contrast studies reveal negative results are found to have esophageal perforation on barium contrast studies.
  • CT scanning may be performed if contrast esophagraphy cannot be performed, cannot localize rupture, or is nondiagnostic.12 If the patient has been sedated, delay contrast studies pending the return of the gag reflex. Look for the following signs:
    • Air in the soft tissue of the mediastinum surrounding the esophagus
    • Abscess cavities in the pleural space/mediastinum
    • Communication of the esophagus with mediastinal fluid collections
  • For more information on imaging of this condition, see eMedicine Radiology article Esophagus, Tear.

Other Tests

  • Other tests depend on the results of esophagram.
    • MRI, CT scanning, or both may be indicated for dissection of aorta.
    • Ventilation/perfusion (V/Q) and/or CT scanning of the lungs may reveal pulmonary embolism.
    • ECG may exclude myocardial infarction or associated cardiac abnormalities.

Diagnostic Procedures

  • Esophagogastroduodenoscopy is not recommended for acute esophageal rupture.
  • Thoracentesis, though rarely needed, may reveal acidic pH, elevated salivary amylase, purulent malodorous fluid, or the presence of undigested food in pleural aspirate, which help confirm the diagnosis.

More on Esophageal Rupture

Overview: Esophageal Rupture
Workup: Esophageal Rupture
Treatment: Esophageal Rupture
Follow-up: Esophageal Rupture
Multimedia: Esophageal Rupture
References
[ CLOSE WINDOW ]

References

  1. Derbes VJ, Mitchell RE Jr. Hermann Boerhaave's (1) atrocis, nec Descripti priu, morbi Historia; (2) the first translation of the classic case report of rupture of the esophagus, with annotations. Bull Med Libr Assoc. 1955;43:217.

  2. Scott HJ, Rosin RD. Thoracoscopic repair of a transmural rupture of the oesophagus (Boerhaave's syndrome). J R Soc Med. Jul 1995;88(7):414P-415P. [Medline].

  3. Bobo WO, Billups WA, Hardy JD. Boerhaave's syndrome: a review of six cases of spontaneous rupture of the esophagus secondary to vomiting. Ann Thorac Surg. 1969;172:1034-1038.

  4. Sozio MS, Cave M. Boerhaave's syndrome following chiropractic manipulation. Am Surg. May 2008;74(5):428-9. [Medline].

  5. Macchi V, Porzionato A, Bardini R, Parenti A, De Caro R. Rupture of Ascending Aorta Secondary to Esophageal Perforation by Fish Bone. J Forensic Sci. Jul 17 2008;[Medline].

  6. Curci JJ, Horman MJ. Boerhaave's syndrome: The importance of early diagnosis and treatment. Ann Surg. Apr 1976;183(4):401-8. [Medline].

  7. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. Sep 1986;42(3):235-9. [Medline].

  8. Bradley SL, Pairolero PC, Payne WS, Gracey DR. Spontaneous rupture of the esophagus. Arch Surg. Jun 1981;116(6):755-8. [Medline].

  9. Brewer LA, Carter R, Mulder GA, Stiles QR. Options in the management of perforations of the esophagus. The American Journal of Surgery. Jul 1986;152:62-69. [Medline].

  10. Henderson JA, Peloquin AJ. Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader. Am J Med. May 1989;86(5):559-67. [Medline].

  11. Richardson JD, Martin LF, Borzotta AP, Polk HC Jr. Unifying concepts in treatment of esophageal leaks. Am J Surg. Jan 1985;149(1):157-62. [Medline].

  12. Jaworski A, Fischer R, Lippmann M. Boerhaave's syndrome. Computed tomographic findings and diagnostic considerations. Arch Intern Med. Jan 1988;148(1):223-4. [Medline].

  13. Brown RH Jr, Cohen PS. Nonsurgical management of spontaneous esophageal perforation. JAMA. Jul 14 1978;240(2):140-2. [Medline].

  14. Cameron JL, Kieffer RF, Hendrix TR. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg. 1979;27:404-408.

  15. Shaffer HA Jr, Valenzuela G, Mittal RK. Esophageal perforation. A reassessment of the criteria for choosing medical or surgical therapy. Arch Intern Med. Apr 1992;152(4):757-61. [Medline].

  16. Sabanathan S, Eng J, Richardson J. Surgical management of intrathoracic oesophageal rupture. Br J Surg. Jun 1994;81(6):863-5. [Medline].

  17. Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg. Feb 2006;81(2):467-72. [Medline].

  18. Kim JH, Song HY, Shin JH, et al. Palliative treatment of unresectable esophagogastric junction tumors: balloon dilation combined with chemotherapy and/or radiation therapy and metallic stent placement. J Vasc Interv Radiol. Jun 2008;19(6):912-7. [Medline].

  19. Harries K, Masoud A, Brown TH, Richards DG. Endoscopic placement of fibrin sealant as a treatment for a long-standing Boerhaave's fistula. Dis Esophagus. 2004;17(4):348-50. [Medline].

  20. Lyons WS, Seremetis MG, deGuzman VC, Peabody JW Jr. Ruptures and perforations of the esophagus: the case for conservative supportive management. Ann Thorac Surg. Apr 1978;25(4):346-50. [Medline].

  21. Pate JW, Walker WA, Cole FH Jr. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg. May 1989;47(5):689-92. [Medline].

  22. Griffin SM, Lamb PJ, Shenfine J, Richardson DL, Karat D, Hayes N. Spontaneous rupture of the oesophagus. Br J Surg. Sep 2008;95(9):1115-20. [Medline].

  23. Anderson RL. Spontaneous rupture of the esophagus. Am J Surg. Feb 1957;93(2):282-90. [Medline].

  24. DeMeester TR. Perforation of the esophagus. Ann Thorac Surg. Sep 1986;42(3):231-2. [Medline].

  25. Graeber GM, Niezgoda JA, Albus RA, Burton NA, Collins GJ, Lough FC, et al. A comparison of patients with endoscopic esophageal perforations and patients with Boerhaave's syndrome. Chest. Dec 1987;92(6):995-8. [Medline].

  26. Infatolino A, Ter RB. Rupture and perforation of the esophagus. In: The esophagus. 3rd ed. 1999:595-605.

  27. Justicz AG, Symbas PN. Spontaneous rupture of the esophagus: immediate and late results. Am Surg. Jan 1991;57(1):4-7. [Medline].

  28. Kossick PR. Spontaneous rupture of the oesophagus. S Afr Med J. Oct 6 1973;47(39):1807-9. [Medline].

  29. Larrieu AJ, Kieffer R. Boerhaave syndrome: report of a case treated non-operatively. Ann Surg. 1974;181:452-454.

  30. Netter FH. Upper digestive tract. The Ciba collection of medical illustrations. 1971;3:44.

  31. O'Connell ND. Spontaneous rupture of the esophagus. Am J Roentgenol Radium Ther Nucl Med. Jan 1967;99(1):186-203. [Medline].

  32. Orringer MB, Stirling MC. Esophagectomy for esophageal disruption. Ann Thorac Surg. Jan 1990;49(1):35-42; discussion 42-3. [Medline].

  33. Sherr HP, Light RW, Merson MH, Wolf RO, Taylor LL, Hendrix TR. Origin of pleural fluid amylase in esophageal rupture. Ann Intern Med. Jun 1972;76(6):985-6. [Medline].

  34. Tong BC, Yang SC, Harmon J. Esophageal perforation. In: Principles of Surgery. 8th ed. 2004:10-14.

  35. Troum S, Lane CE, Dalton ML Jr. Surviving Boerhaave's syndrome without thoracotomy. Chest. Jul 1994;106(1):297-9. [Medline].

  36. Walker WS, Cameron EW, Walbaum PR. Diagnosis and management of spontaneous transmural rupture of the oesophagus (Boerhaave's syndrome). Br J Surg. Mar 1985;72(3):204-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

esophageal rupture, esophageal surgery, esophagus rupture, esophageal tear, tear esophagus, Boerhaave syndrome, boerhaave syndrome, Boerhaave, iatrogenic rupture, esophagus, esophageal perforation, esophageal disruption, anastomotic leak, esophagitis, esophageal ulcer, esophageal neoplasm, necrotizing mediastinitis, mediastinal emphysema, hydropneumothorax, sepsis, Mackler triad, endoscopy, esophagogastroduodenoscopy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Dale K Mueller, MD, Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois at Peoria; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC
Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, American Medical Writers Association, Chicago Medical Society, Illinois State Medical Society, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Yogesh Govil, MD, MRCP, Consulting Staff, Department of Internal Medicine, Division of Gastroenterology, Crozer-Chester Medical Center
Yogesh Govil, MD, MRCP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Thomas E Kowalski, MD, Assistant Professor, Department of Medicine, Director, Gastrointestinal Endoscopy Unit, Thomas Jefferson University, Consulting Staff, Thomas Jefferson University Hospital
Disclosure: Nothing to disclose.

Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwestern Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Benson B Roe, MD, Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center
Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.