Esophageal Rupture and Tears in Emergency Medicine Treatment & Management

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

Next:

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.

Although 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.

The Systemic Inflammatory Response Score (SIRS) may offer a useful triage tool in determining need for operative intervention versus a conservative approach. A positive score denotes the need for operative intervention.

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.

Hospitalization

Patients almost uniformly require intensive care unit admission because they may become septic and can have a complicated hospital course.

Patients managed conservatively should take nothing by mouth and be administered parenteral antibiotics for 7-10 days; consideration should be given to intravenous nutrition in the event of a prolonged course. Repeat esophageal studies are utilized to ascertain treatment success.

Transfer

Patients with Boerhaave syndrome must be treated in a center with access to intensive care and cardiothoracic surgery. Transfer may be required to a tertiary care facility if these services are not available at the presenting hospital.

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