eMedicine Specialties > Emergency Medicine > Gastrointestinal
Esophageal Perforation, Rupture and Tears: Treatment & Medication
Updated: Mar 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
Any patient with an esophageal tear should be expeditiously transported to the emergency department with intravenous access, supplemental oxygen with a secure airway, and pain medication as necessary.
Emergency Department Care
- Consideration of esophageal perforation as a diagnosis is the first and most important step in management. Emergency department treatment of any patient with suspected esophageal perforation depends on the severity of the injury and the patient's hemodynamic stability, but will always include large-bore intravenous access, supplemental oxygen as necessary, and cardiopulmonary monitoring before further treatment is considered.
- Administration of broad-spectrum intravenous antibiotics should be instituted early in the evaluation.
- Patient should be made NPO and have a nasogastric tube placed to clear gastric contents and limit further contamination.
- Patient pain and discomfort may be significant; narcotic analgesia should be given as needed, judiciously in hypotensive patients.
- Patients with tenuous hemodynamic stability or any degree of airway compromise, especially those with Boerhaave syndrome, should undergo treatment in a setting with complete resuscitative facilities, including emergency airway equipment, as clinical decompensation can be precipitous.
- Rarely, tube thoracostomy may be urgently used to decompress the chest. Fluid removed is often gastric contents, occasionally pus, which is often present after significant delay in diagnosis.
- While historically treated exclusively with surgery, emerging evidence indicates that patients with small well-defined tears and minimal extraesophageal involvement may be better served by conservative treatment as outlined above.
- Originally put fourth by Cameron et al in 1979 and modified by Altorjay in 19973 , the following represent suggested criteria for nonoperative management: Early diagnosis or delayed diagnosis with contained leak; tear outside abdomen, contained to mediastinum, draining to esophagus; draining to esophageal lumen by esophagography; tear does not involve neoplasm or obstruction; no signs or symptoms of sepsis; experienced thoracic surgeon and contrast imaging available.
- Specific surgical technique (primary repair, stent, resection, or drain placement) depends on the extent and location of injury, and is beyond the scope of this discussion.
Consultations
Obtain an emergent surgical consultation, cardiothoracic if available, as even patients initially managed nonoperatively could require surgery.
Medication
Analgesia and antibiotics are required for management.
Analgesics
Pain control is essential to quality patient care. Ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties that are beneficial to patients who have sustained trauma.
Morphine sulfate (Duramorph, Astramorph, MS Contin)
DOC for narcotic analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
IV doses may be administered in a number of ways, commonly titrated until desired effect is obtained.
Adult
Sedation/analgesia before procedures: 3-4 mg IV q5min prn
Initial dose: 0.1 mg/kg IV/IM/SC
Analgesia: 2.5-20 mg IV/IM/SC q2-6h prn
Continuous infusion: 0.8-10 mg IV q1h
Pediatric
Emergency: 0.1-0.2 mg/kg IV
Analgesia: 0.1-0.2 mg/kg IV/IM/SC q2-6h prn
Continuous infusion: 0.01-0.04 mg/kg IV q1h
Maximum dose: 15 mg
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control is difficult
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Antiemetics
Useful in treating symptomatic nausea and preventing further contamination of pleural space.
Prochlorperazine (Compazine)
An antidopaminergic drug that blocks postsynaptic mesolimbic dopamine receptors. Has an anticholinergic effect and can depress the reticular activating system. May be responsible for relieving nausea and vomiting.
Adult
5-10 mg IV q2min
Pediatric
<10 kg: Do not administer
>10 kg: 0.1-0.2 mg/kg IV
Coadministration with other CNS depressants or anticonvulsants may cause additive effects; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; bone marrow suppression, narrow-angle glaucoma, and severe liver or cardiac disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Drug-induced Parkinson syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most common extrapyramidal reaction in elderly persons; lowers seizure threshold; caution with history of seizures
Metoclopramide (Reglan)
Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, which provides important antiemetic activity.
Adult
5-10 mg PO or 5-20 mg IV/IM tid prn
Pediatric
1-2 mg/kg IV/IM 30 min before chemotherapy and q2-4h
Anticholinergic agents may antagonize effects of metoclopramide; opiate analgesics may increase metoclopramide toxicity in CNS
Documented hypersensitivity; pheochromocytoma or GI hemorrhage, obstruction or perforation; history of seizure disorders
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in history of mental illness and Parkinson disease
Promethazine (Phenergan)
For symptomatic treatment of nausea in vestibular dysfunction. Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.
Adult
12.5-25 mg PO/IV/IM/PR q4h prn
Pediatric
<2 years: Contraindicated
>2 years: 0.25-1.0 mg/kg PO/IV/IM/PR 4-6 times/d prn
May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; children younger than 2 y (incidences of death due to respiratory depression)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Imipenem and cilastatin (Primaxin)
Used for treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of their potential for toxicity.
Adult
500-1000 mg IV q6h
Patients with impaired renal function need lower doses
Pediatric
Infants >3 months and children <12 years: 50 mg/kg/d IV divided tid/qid
Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency (adult adjustments)
CrCl (mL/min) 80-50: 0.5 g q6-8h
CrCl 50-10: 0.5 g q8-12h
Hemodialysis (HD): 0.25-0.5 g after HD, then q12h
Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections
Caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta lactam antibiotics
Piperacillin and tazobactam sodium (Zosyn)
Semisynthetic extended-spectrum penicillin that inhibits bacterial cell wall synthesis by binding to specific PBPs; most effective of the antipseudomonal penicillins. Tazobactam increases piperacillin activity against S aureus, Klebsiella, Enterobacter, and Serratia species; (greatest increase in activity against B fragilis) but does not increase anti-P aeruginosa activity.
Intra-abdominal and pelvic infections: The main pathogens in the lower abdomen and pelvis are aerobic coliform gram-bacilli and B fragilis. Enterococci are permissive and opportunistic pathogens and do not require special coverage.
Adult
4.5 g IV q8h (piperacillin 4 g/tazobactam 0.5 g)
Pediatric
<10 years: Not established
>10 years: Administer as in adults
Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
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 |
| « Previous Page | Next Page » |
References
Bernard AW, Ben-David K, Pritts T. Delayed presentation of thoracic esophageal perforation after blunt trauma. J Emerg Med. Jan 2008;34(1):49-53. [Medline].
Sinha R. Naclerio's V sign. Radiology. Oct 2007;245(1):296-7. [Medline].
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].
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].
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].
Braghetto I, Rodríguez A, Csendes A, Korn O. [An update on esophageal perforation]. Rev Med Chil. Oct 2005;133(10):1233-41. [Medline]. [Full Text].
Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. Apr 2004;77(4):1475-83. [Medline].
Bufkin BL, Miller JI Jr, Mansour KA. Esophageal perforation: emphasis on management. Ann Thorac Surg. May 1996;61(5):1447-51; discussion 1451-2. [Medline].
Chong CF. Esophageal rupture due to Sengstaken-Blakemore tube misplacement. World J Gastroenterol. Nov 7 2005;11(41):6563-5. [Medline].
Cordero JQ. Distal esophageal rupture after external blunt trauma: report of two cases. J Trauma. 1997;42(2):321-322. [Medline].
Eroglu A, Can Kurkcuogu I, Karaoganogu N, Tekinbas C, Yimaz O, Basog M. Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus. 2004;17(1):91-4. [Medline].
Gupta NM, Kaman L. Personal management of 57 consecutive patients with esophageal perforation. Am J Surg. Jan 2004;187(1):58-63. [Medline].
Inculet R, Clark C, Girvan D. Boerhaave's syndrome and children: a rare and unexpected combination. J Pediatr Surg. Sep 1996;31(9):1300-1. [Medline].
Jagminas L, Silverman RA. Boerhaave's syndrome presenting with abdominal pain and right hydropneumothorax. Am J Emerg Med. Jan 1996;14(1):53-6. [Medline].
Johnsson E, Lundell L, Liedman B. Sealing of esophageal perforation or ruptures with expandable metallic stents: a prospective controlled study on treatment efficacy and limitations. Dis Esophagus. 2005;18(4):262-6. [Medline].
Kaneda T, Onoe M, Asai T. Delayed esophageal necrosis and perforation secondary to thoracic aortic rupture: a case report and review of the literature. Thorac Cardiovasc Surg. Dec 2005;53(6):380-2. [Medline].
Lowell M, Barsan WG. Esophageal perforation. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 2005:1237-8.
Lowell M, Barsan WG. Esophageal perforation. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. C. V. Mosby; 2002:1237-8.
Lujan HJ, Lin PH, Boghossian SP, Yario RF, Tatooles CJ. Recurrent spontaneous rupture of the esophagus: an unusual late complication of Boerhaave's syndrome. Surgery. Sep 1997;122(3):634-6. [Medline].
Ochiai T, Hiranuma S, Takiguchi N, Ito K, Maruyama M, Nagahama T. Treatment strategy for Boerhaave's syndrome. Dis Esophagus. 2004;17(1):98-103. [Medline].
Panieri E, Millar AJ, Rode H, et al. Iatrogenic esophageal perforation in children: patterns of injury, presentation, management, and outcome. J Pediatr Surg. Jul 1996;31(7):890-5. [Medline].
Ring D, Vaccaro AR, Scuderi G, Green D. Vertebral osteomyelitis after blunt traumatic esophageal rupture. Spine. Jan 1 1995;20(1):98-101. [Medline].
Rubesin SE, Levine MS. Radiologic diagnosis of gastrointestinal perforation. Radiol Clin North Am. Nov 2003;41(6):1095-115, v. [Medline].
Sabanathan S, Eng J, Richardson J. Surgical management of intrathoracic oesophageal rupture. Br J Surg. Jun 1994;81(6):863-5. [Medline].
Troum S, Lane CE, Dalton ML Jr. Surviving Boerhaave's syndrome without thoracotomy. Chest. Jul 1994;106(1):297-9. [Medline].
Vial CM, Whyte RI. Boerhaave's syndrome: diagnosis and treatment. Surg Clin North Am. Jun 2005;85(3):515-24, ix. [Medline].
Further Reading
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
