Esophageal Rupture and Tears in Emergency Medicine Clinical Presentation

  • Author: Corey M Long, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Apr 28, 2011
 

History

  • The classic presentation of spontaneous esophageal rupture is severe vomiting or retching followed by acute, severe chest or epigastric pain.
  • Boerhaave syndrome has also been reported with abdominal or chest pain following straining, childbirth, weight lifting, fits of coughing or laughing, hiccuping, blunt trauma, seizures, and forceful swallowing.
  • The presence of fever; pain in the neck, upper back, chest, or abdomen; dysphagia; odynophagia; dysphonia; or dyspnea following esophageal instrumentation should raise suspicion for perforation.
  • Patients with thoracic or abdominal perforations may present with any of the above symptoms, as well as low back pain, shoulder pain referred from diaphragmatic irritation, increased discomfort lying flat, or true acute abdomen.
  • The ingestion of a caustic toxin or foreign body preceding any of the above symptoms may indicate perforation.
  • A history of preexisting upper gastrointestinal pathology (gastroesophageal reflux disease, hiatal hernia, carcinoma, strictures, radiation therapy, Barrett esophagus, varices, achalasia, infection) raises a patient's risk of perforation.
  • Hematemesis, while occasionally present, is normally not a predominant symptom.
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Physical

  • Although the physical examination is often nonspecific, certain findings can be helpful.
  • Subcutaneous emphysema is palpable in the neck or chest in up to 60% of perforations but requires at least an hour to develop after the initial injury.
  • Tachycardia and tachypnea are common initial physical examination findings, but fever may not be present for hours to days.
  • The Mackler triad, consisting of vomiting, chest pain, and subcutaneous emphysema, is classically associated with spontaneous esophageal rupture, though it is only fully present in about 50% of cases.
  • Auscultation of the chest can be of particular value. The Hamman sign is a raspy, crunching sound heard over the precordium with each heartbeat caused by mediastinal emphysema, often present with thoracic or abdominal perforations. Breath sounds may be reduced on the side of the perforation due to a contamination of the pleural space, often on the left.
  • In cases of delayed presentation, patients may be critically ill and present with significant hypotension.
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Causes

  • Iatrogenic etiologies predominate the causes of esophageal perforation, accounting for up to 85% of cases. Instrumentation modalities commonly include endoscopy, sclerotherapy, variceal ligation, pneumatic dilation, bougienage, and laser treatment. Placement of endotracheal, nasogastric, and Blakemore tubes represent less common iatrogenic causes.
  • As detailed above, Boerhaave syndrome consistently accounts for about 15% of all perforations, normally secondary to vomiting after heavy food and alcohol intake, but possible by any action that abruptly increases intra-abdominal pressure against a closed superior esophageal sphincter.
  • Swallowed foreign bodies may directly injure the esophagus by penetrating the tissue or becoming lodged at a point of esophageal narrowing, leading to pressure necrosis and wall weakness; pills and coins are common culprits. Ingestion of caustic chemicals may lead to direct wall inflammation and damage.
  • Trauma represents an important cause of perforation, estimated at up to 10% of cases. Penetrating trauma is much far more prevalent than blunt, often in the form of knife or gun wounds, and is associated with significant injury to important adjacent cervical structures. Blunt trauma may affect any portion of the esophagus[1] , and the diagnosis is often delayed secondary to other injuries.
  • Intraoperative esophageal perforation is a recognized complication of surgery, especially cardiothoracic or fundoplication, accounting for around 2% of all perforations.
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Contributor Information and Disclosures
Author

Corey M Long, MD  Resident, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center

Corey M Long, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Ugo Anthony Ezenkwele, MD, MPH  Assistant Professor of Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center

Ugo Anthony Ezenkwele, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD  Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows a false tract emanating from the esophagus (arrow).
Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows leakage of oral contrast material (blue arrow) and air in the posterior mediastinum (red arrow).
Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
 
 
 
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