eMedicine Specialties > Emergency Medicine > Gastrointestinal

Esophageal Perforation, Rupture and Tears: Differential Diagnoses & Workup

Author: Corey M Long, MD, Resident, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center
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
Contributor Information and Disclosures

Updated: Mar 23, 2009

Differential Diagnoses

Acute Coronary Syndrome
Pericarditis and Cardiac Tamponade
Aneurysm, Abdominal
Pneumonia, Aspiration
Dissection, Aortic
Pneumonia, Bacterial
Gastritis and Peptic Ulcer Disease
Pneumonia, Empyema and Abscess
Myocardial Infarction
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Pancreatitis
Pulmonary Embolism

Other Problems to Be Considered

Mallory-Weiss tear

Workup

Laboratory Studies

  • Laboratory studies are of little value in confirming the diagnosis.
  • If a diagnostic thoracentesis is performed on a pleural effusion, the presence of food particles, pH <6, or an elevated pleural fluid amylase are compatible with esophageal perforation.

Imaging Studies

  • Chest radiographs can be very helpful in diagnosing esophageal perforation, with suggestive abnormalities reported in about 90% of cases.
    • Pneumomediastinum and subcutaneous emphysema are often present an hour after the injury and are highly suggestive of perforation.
    • Mediastinal air-fluid levels, pleural effusions (often left sided), free air under diaphragm, pneumothorax, and hydropneumothorax encompass later potential findings.
    • The V sign classically seen in esophageal perforation is indicative of pneumomediastinum. Air outlines the left lower mediastinal border and medial left hemidiaphragm, forming a "V".2
  • Lateral neck radiographs may demonstrate air in the fascial planes early in cases of cervical perforations.
  • A contrast esophagogram should be performed in any patient with suspected perforation.
    • Despite a modest sensitivity (60-75%), a water-soluble contrast agent (Gastrografin) should be the initial study of choice.
    • A barium study should be undertaken immediately afterward should the initial study show no evidence of perforation.
    • Barium has a higher sensitivity (90%) for detecting small perforations but may cause a severe inflammatory response in tissues, most notably a mediastinitis.
    • Studies should be performed with the patient in the right lateral decubitus position.
Water-soluble contrast esophagram from a patient ...

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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Water-soluble contrast esophagram from a patient ...

Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).

  • A contrast-enhanced CT scan of the chest should be obtained if it is not possible to obtain a contrast esophagogram, if the esophagogram was negative despite a high clinical suspicion, or if seeking to evaluate for a more likely alternative diagnosis. Perforation may be suggested by mediastinal air, extravasated luminal contrast, periesophageal fluid collections, pleural effusions, or actual communication of an air-filed esophagus with an adjacent mediastinal air-fluid collection; definitive esophageal communication with outside structures is often difficult to visualize.

Other Tests

  • Esophagoscopy often can be used to visualize perforations and is especially useful in acute traumatic perforations, but it is not appropriate when small mucosal tears are suspected, as insufflated air can cause further dissection of the perforation.

More on Esophageal Perforation, Rupture and Tears

Overview: Esophageal Perforation, Rupture and Tears
Differential Diagnoses & Workup: Esophageal Perforation, Rupture and Tears
Treatment & Medication: Esophageal Perforation, Rupture and Tears
Follow-up: Esophageal Perforation, Rupture and Tears
Multimedia: Esophageal Perforation, Rupture and Tears
References
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References

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  2. Sinha R. Naclerio's V sign. Radiology. Oct 2007;245(1):296-7. [Medline].

  3. Altorjay A, Kiss J, Voros A, Bohak A. Nonoperative management of esophageal perforations. Is it justified?. Ann Surg. Apr 1997;225(4):415-21. [Medline].

  4. Adamek HE, Jakobs R, Dorlars D, Martin WR, Kromer MU, Riemann JF. Management of esophageal perforations after therapeutic upper gastrointestinal endoscopy. Scand J Gastroenterol. May 1997;32(5):411-4. [Medline].

  5. Borotto E, Gaudric M, Danel B, Samama J, Quartier G, Chaussade S. Risk factors of oesophageal perforation during pneumatic dilatation for achalasia. Gut. Jul 1996;39(1):9-12. [Medline].

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Further Reading

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Keywords

esophageal perforation, esophageal rupture, esophageal tear, esophagus tear, Boerhaave's syndrome, Boerhaave syndrome, iatrogenic perforation, esophagus, Mackler's triad, Hamman sign, blunt trauma, treatment, causes, symptoms, penetrating trauma to the neck, Mallory-Weiss tear, gastroesophageal reflux disease, spontaneous esophageal rupture 

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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.

Medical Editor

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, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

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, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier 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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