Esophageal Perforation and Acute Mediastinitis
Cynthia E. Weber
Fred A. Luchette
Robert M. Mentzer Jr
I. ESOPHAGEAL PERFORATION
A. Definitions. Esophageal perforation can be a result of multiple pathophysiologic etiologies.
1. “Spontaneous” perforation due to increased wall tension.
2. Penetrating injuries.
a. Due to intraluminal pathology.
b. Result of extraluminal causes.
B. Etiology.
1. Spontaneous (barogenic) perforation.
a. Rapid increase in intraluminal pressure (violent vomiting—Boerhaave syndrome, blunt trauma).
b. Necrosis of the esophageal wall from esophageal cancer.
c. Inflammatory esophageal lesions: tuberculosis, Barrett esophagus, idiopathic eosinophilic esophagitis.
2. Extraluminal perforation.
a. Penetrating trauma from stab or gunshot wounds.
b. Esophageal surgery: resection or esophagomyotomy.
c. Adjacent surgical procedures: cervical procedures, truncal vagotomy, pneumonectomy, laparoscopic Nissen fundoplication, aortic surgery, atrial fibrillation procedures through surgical or percutaneous approach, hiatal hernia repair, thoracic aneurysm repair, tracheostomy, and tube thoracostomy.
3. Intraluminal perforation.
a. Instrumentation.
i. More common with rigid than flexible endoscopy.
ii. More common during interventions such as balloon dilation of a stricture.
iii. Leading edge of a stricture is the point most likely to rupture.
b. Esophageal stent placement, especially in the setting of prior radiation or chemotherapy.
c. Congenital anomalies (esophageal atresia) or from nasogastric (NG) tube placement.
d. Transesophageal echocardiography—very rare.
e. Endotracheal intubation.
f. Ingested foreign bodies.
g. Chemical burns from alkali or strong acids, resulting in mucosal damage and stricture.
h. Reflux esophagitis with ulceration.
i. Endoscopic sclerotherapy, laser therapy, photodynamic therapy.
C. Clinical presentation.
1. Tachycardia—earliest sign of mediastinitis.
2. Tachypnea.
3. Subcutaneous emphysema of the face and chest.
4. Pain: precordial, substernal, epigastric, or scapular due to diaphragmatic irritation.
5. Fever.
6. Dysphagia and odynophagia.
7. Hoarseness and cervical tenderness in cervical esophageal perforations.
D. Diagnosis.
1. Chest radiography (CXR): mediastinal air, hydropneumothorax, pleural effusion, subcutaneous emphysema.
2. Contrast esophagram—most sensitive diagnostic test; water-soluble contrast preferred; can confirm with barium if needed.
3. Computed tomography (CT) scan: extraluminal air, periesophageal fluid, wall thickening, extraluminal contrast.
4. Possible role for endoscopy to aid in diagnosis.
E. Treatment.
1. Early (<24 hours from the time of perforation).
a. Primary closure with wide drainage of the mediastinum.
