Esophageal Rupture and Tears in Emergency Medicine Clinical Presentation

Updated: Oct 13, 2016
  • Author: Ugo Anthony Ezenkwele, MD, MPH; Chief Editor: Steven C Dronen, MD, FAAEM  more...
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Presentation

History

The classic presentation of spontaneous esophageal rupture is severe vomiting or retching followed by acute, severe chest or epigastric pain. Other symptoms may include the following:

  • 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.
  • Older age (>65 y) is a significant risk factor for perforation during instrumentation.
  • 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, including the following:

  • 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 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.

Boerhaave syndrome

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.

Foreign bodies

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

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

Intraoperative esophageal perforation is a recognized complication of surgery, especially cardiothoracic or fundoplication, accounting for around 2% of all perforations.

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