Esophageal Rupture and Tears in Emergency Medicine Treatment & Management

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

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.

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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 1997[3] , 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.
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Consultations

Obtain an emergent surgical consultation, cardiothoracic if available, as even patients initially managed nonoperatively could require surgery.

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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.

References

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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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