Esophageal Perforation

Etiology

Esophagogastroduodenoscopy (EGD): most common etiology
- Esophageal Variceal Sclerotherapy (see Esophageal Varices, [[Esophageal Varices]])
Boerhaave’s Syndrome: emetogenic esophageal rupture
Sengstaken-Blakemore Tube
Esophageal Foreign Body
Esophageal Cancer (see Esophageal Cancer, [[Esophageal Cancer]])

Esophageal Perforation with Acute Mediastinitis
- Most cases have subsequent pleural space infection

Pleural Fluid
- pH: decreased (often <7.0)
- Cholesterol: elevated >55-60 mg/dL (seen in all exudates)
- Pleural Fluid Amylase: elevated
- Pleural/Serum Cholesterol Ratio: elevated (elevated ratio is seen in all exudates)
- Cell Count/Differential: elevated WBC with PMN-predominance
- Cytology: meat (muscle) or vegetable matter may be seen
CXR/Chest CT Patterns: 90% of cases have abnormal CXR
- Left Pleural Effusion: usual finding
- Mediastinal or Subcutaneous Emphysema
- Infiltrates
- Pneumoperitoneum: seen in some cases
Esophogram: use Meglumine Diatrizoate (Gastrografin)
- Usually diagnostic: demonstrates leak into left pleural space
- If negative, do Barium esophagram
ABG: metabolic acidosis (due to acute mediastinitis with sepsis)
Esophagogastroduodenoscopy (EGD): low sensitivity
- May enlarge perforation, as well

Dyspnea (see Dyspnea, [[Dyspnea]])
Pleural Effusion (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]])

Surgical Repair: usually required early
Medical Management: may be indicated for clinically stable cases, instrumentation-associated cases with early or late discovery and good tolerance of perforation, and well-contained perforations (with containment in loculated pleural space/mediastinum: no SQ emphysema, PTX, or pneumoperitoneum)

Mortality: 22-63% mortality if detected within first 24 hrs (higher mortality with later detection)