Esophageal Rupture and Tears in Emergency Medicine Clinical Presentation

Updated: Nov 15, 2022
  • 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. Boerhaave syndrome has also been reported with abdominal or chest pain following straining, childbirth, weightlifting, fits of coughing or laughing, hiccupping, 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.

Any of the above symptoms related to the ingestion of a caustic toxin or foreign body may indicate perforation.

Older age (>65 y) is a significant risk factor for perforation during instrumentation. 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 Examination

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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