Esophageal perforation: Clinical sciences

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Introduction0:00–0:57

Esophageal perforation is a serious condition in which a hole in the esophagus exposes the surrounding tissues to the contents of the gastrointestinal tract.
Esophageal perforation typically results from iatrogenic trauma, for example in patients who recently underwent upper endoscopy or placement of a feeding tube.
The second most common cause is Boerhaave syndrome due to forceful vomiting, and perforations can also result from swallowing foreign objects.
Now, some individuals have anatomic etiologies that put them at higher risk for perforation such as Zenker diverticulum or esophageal stricture.
When it comes to the site of the perforation, it most commonly occurs in the left posterolateral aspect of the distal intrathoracic esophagus.
Esophageal perforation can lead to severe and fatal complications like mediastinitis and sepsis. Your first step in assessing a patient with a chief concern suggestive of esophageal perforation is to perform an ABCDE assessment to determine if the patient is stable or unstable.

Unstable patient - History and Physical0:57–3:53

If the patient is unstable, start acute management immediately to stabilize the airway, breathing, and circulation. Next, obtain IV access, start fluid resuscitation, keep the patient NPO, administer antibiotics, and give IV proton pump inhibitors as soon as possible.
Once you have initiated the acute management, your next step is to obtain a focused history, physical exam, and order labs like CBC, ABG, blood cultures, and lactate.Alright, let's talk about history and physical examination.
Symptoms may include fever, chills, and altered mental status. A patient will often have neck, chest, interscapular, and/or abdominal pain.
Additionally, they might report dysphagia, odynophagia, or dyspnea. Lastly, some clues in history can point to the cause of the perforation.
If a patient reports forceful vomiting, you should think about Boerhaave syndrome, which is when straining due to forceful vomiting causes esophageal perforation.
Other clues to the cause include a history of foreign body ingestion, alcohol use disorder, or recent endoscopy.Here’s a high-yield fact!
If you find all elements of the Mackler triad, which includes history of vomiting, retrosternal pain, and subcutaneous emphysema, you can suspect Boerhaave syndrome as the most likely cause of the esophageal perforation.
Now, when it comes to the physical exam, it may reveal signs of sepsis, such as fever, tachycardia, tachypnea, and hypotension.
Now, once the esophagus is perforated air will get into spaces it is not supposed to be in. So, other important findings to look out for include crepitus and subcutaneous emphysema.
Subcutaneous emphysema and crepitus around the suprasternal notch and neck point to cervical perforation. Subcutaneous emphysema and crepitus on the chest wall are probably caused by thoracic perforation.
Now, if a patient is having mediastinal emphysema, you’ll hear crackling when you auscultate the lungs. As you are auscultating the chest, be on the lookout for the Hamman sign, which is characterized by a crunching sound over the apex of the heart that is in sync with the heartbeat.
The Hamman sign is actually caused by the heart beating against the air in the chest cavity. As for the labs, they might reveal leukocytosis and bacteremia, which would indicate an infection.
You may also see metabolic acidosis and elevated lactate levels from sepsis and subsequent hypoperfusion.Okay, if you see these findings in history, physical exam, and labs, you should suspect an esophageal perforation.

Unstable patient - Imaging3:53–4:41

The next step is to confirm the diagnosis with some imaging. Obtain neck, upright chest, and abdominal x-rays.
The x-ray may show a pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema, or pleural effusion. Since these signs point to the possibility of esophageal perforation, the next step would be to obtain a confirmatory study like a contrast esophagography to check for any small leaks.
If this study is positive, you can diagnose an esophageal leak secondary to a perforation and possible mediastinitis.Now that we have our diagnosis, let’s move on to management.

Unstable patient - Management4:41–5:17

Start with broad-spectrum antibiotics and antifungals, since microorganisms will have leaked out from the esophagus. Next, you want to keep the patient NPO and provide nutritional support, which requires total parenteral nutrition, or TPN.
Finally, be sure to get an emergent surgical consultation for immediate intervention.Alright, now that unstable patients are taken care of, let’s talk about stable patients.

​​Stable patients - History and Physical5:17–6:16

Your first step here is to obtain a focused history and physical exam as well as labs including a CBC.The patient's history might reveal neck, chest, interscapular, or abdominal pain.
They might also experience dysphagia, odynophagia, or dyspnea. In addition, they might report nausea and forced vomiting.
Lastly, the patient's history may reveal a foreign body ingestion, alcohol use disorder, or a recent endoscopy.A physical examination might reveal crepitus around the suprasternal notch and neck or on the chest wall from subcutaneous emphysema.
Also, you may encounter the Hamman sign and the Mackler triad. As for the labs, CBC may reveal leukocytosis.Alright, If you see these findings, you should suspect an esophageal perforation.

Stable patient - Imaging6:16–8:09

To confirm your diagnosis, you will need to obtain imaging. First, obtain x-rays of the neck, upright chest, and abdomen.
Now, if the x-rays are not consistent with perforation, contrast esophagography can be ordered to rule out any small perforation.
If there is no evidence of contrast extravasation, consider alternative diagnoses.On the flip side, X-rays may reveal a pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema, or pleural effusion.
Afterward, get a CT chest with IV and PO contrast and, if needed, a contrast esophagography. The CT of the chest will show esophageal wall thickening, pneumomediastinum, pleural effusion, extraluminal oral contrast if it’s given, and possibly a foreign body, as seen on this CT showing a chicken bone in the esophagus.
If the CT is positive, no need for further imaging, but keep in mind that CT may miss small perforations. So if CT is inconclusive, these minor leaks can be diagnosed with contrast esophagography.
If you find extravasation of contrast outside the esophageal lumen, the diagnosis of esophageal perforation is confirmed.Let’s take a break with a high-yield fact!
It is extremely important to avoid barium as a contrast during esophagography, since barium can leak into the mediastinum and worsen mediastinitis.
Instead, you should go with a water-soluble contrast, such as gastrografin.Okay, now that we have our diagnosis, let’s talk about management.

Stable patient - Management8:09–9:28

The management varies depending on the size of the perforation and time of presentation. If there’s small, limited leakage, indicating that the perforation is contained, and the patient presented early to the hospital, you can start with conservative management.
You should continuously monitor the patient’s vital signs, make them NPO, and consider TPN for nutritional support. These patients should also be given medication for pain control, and be started on a proton pump inhibitor or PPI.
Lastly, obtain surgical consultation for possible intervention.Alright, let’s consider another possibility. In case of large, extended leakage into the mediastinum, indicating non-contained perforation, or those with delayed hospital presentation, urgent surgical management is required, as these are considered non-contained perforations.
The treatment involves broad-spectrum antibiotics and antifungals, NPO, nutritional support with TPN, pain control, PPI, and emergent surgical consultation for intervention.Alright, as a quick recap… Esophageal perforation is a serious condition that occurs when there is a hole in the esophagus, and can have severe or fatal complications.

Review9:28–10:39

Unstable patients should be evaluated with neck, chest, and abdominal x-rays, as well as contrast esophagography. Once the diagnosis is made, you can treat them with antibiotics and antifungals, while keeping them NPO and on TPN, and obtain emergent surgical consultation for immediate intervention.
When it comes to stable patients, they should be evaluated with neck, chest, and abdominal x-rays, as well as a chest CT and, if needed, contrast esophagography.
Patients with small, limited leakage and contained perforation can be managed conservatively with pain management, PPI, and nutritional support, as well as surgical consultation for possible intervention.
On the other hand, patients with large, non-contained perforation need antibiotics, antifungals, pain management, PPI, nutritional support, and emergent surgical consultation for intervention.