Esophageal Perforation

Causes

1. Iatrogentic perforation is most common.

2. transient increase in intraesophageal pressure (Boerhaave syndrome),

3. trauma,

4. foreign body,

5. infection,

6. tumor,

7. aortic pathology.

Symptoms

1. Pain→ acute, severe, unrelenting,

2. diffuse in the chest, neck, and abdomen.

3. radiate to the back and shoulders,

4. Swallowing exacerbates pain. 

   
   

Sign

1. Abdominal rigidity with hypotension and fever ( early sign )

   
   

2. Tachycardia and tachypnea

3. Mediastinal emphysema (late sign )

4. A Hammon crunch can sometimes be auscultated.

5. Pleural effusions develop in 50% of patients with intrathoracic perforations and are uncommon in cervical perforations.

Investigation

1. Chest radiography can suggest the diagnosis.

   
   

2. esophagram or emergency endoscopy to confirm

Treatment

1. initiate fluid resuscitation

2. give broad-spectrum parental antibiotics to cover aerobic and anaerobic organisms.

   • single drug coverage such as piperacillin/tazobactam 3.375 g intravenously (IV)

   • double drug coverage with :

     • cefotaxime 2 g IV or

     • ceftriaxone 2 g IV plus

     • clindamycin 600 mg IV or

     • Metronidazole 15 mg/kg IV once, then 7.5 mg/kg q6h (maximum 1 g/dose).