Esophageal perforation and mediastinitis

Foreign bodies (button batteries)

Caustic ingestions

Trauma (blunt or penetrating)

Violent emesis (Boerhaave syndrome)

Valsalva (cough, heavy lifting, childbirth)

Severe esophagitis

Peptic esophageal ulcer

Spontaneous

Other iatrogenic causes (nasogastric tube placement, postoperative anastomosis breakdown)

Table 42.2. Common sites of perforation

Etiology	Perforation site
Spontaneous/forceful emesis	Distal posterolateral wall of the esophagus just above the diaphragm
Foreign bodies	Cervical esophagus or site of stricture
Blunt trauma to neck/thorax	Proximal and middle thirds of the esophagus
Caustic ingestions	Diffuse injury: Alkali burns tend to cause more severe disease than acidic burns because of the liquefactive necrosis
Iatrogenic injuries	Any of the following sites:1. Pharyngoesophageal junction (thinnest wall with no serosal layer) 2. Esophagogastric junction (acute curve as esophagus enters abdomen) 3. Sites of known strictures

Presentation

Classic presentation

Pain or fever after recent esophageal instrumentation is esophageal perforation until proven otherwise.
Pain is almost always present and can be in the chest, abdomen, back, or neck.
Meckler’s classic triad includes sharp chest or epigastric pain, violent vomiting, and subcutaneous emphysema; however, it is only present in a minority of cases.
Subcutaneous emphysema can be found on careful examination of the neck and chest wall in approximately 60% of cases.
Hamman’s sign can be present and is the “crunching” sound heard during auscultation of the chest with pneumomediastinum.

Critical presentation

About a third of patients present with atypical symptoms or signs including sepsis, peritonitis, respiratory distress, fever, pneumo/hydrothorax, fulminant shock, and multi-system organ failure.
Approximately 17% of esophageal perforations are diagnosed only at autopsy.

Diagnosis and evaluation

A high index of suspicion is of paramount importance.
The differential diagnosis is listed in Table 42.3.
Chest radiography
- 90% of patients will have findings suggestive of perforation on simple chest radiography; signs to look for (see Figure 42.1) are
  - Left pleural effusion
  - Mediastinal air
  - Subcutaneous emphysema
  - Widened mediastinum
  - Pneumothorax
  - Pulmonary infiltrate.
Additional imaging studies
- A contrast study such as esophagography with Gastrograffin should be performed if perforation is suspected. Although barium has superior sensitivity, it will cause a worsened mediastinal/peritoneal inflammatory response if a leak is present. In addition, Gastrograffin is recommended because it will not obscure visualization during endoscopy. A second study with dilute barium may be considered if an initial study with Gastrograffin is negative (see Figure 42.2).
- Computed tomography (CT) of the chest and abdomen with oral contrast may better define the leak, assess complications, and exclude other diagnoses. With increased availability and improved resolution, CT is often used as first-line imaging modality. CT findings of perforation include
  - Mediastinal air
  - Subcutaneous emphysema
  - Pleural effusion
  - Pneumopericardium
  - Pneumoperitoneum.
Laboratory studies
- Laboratory studies are nonspecific and unreliable, especially initially on presentation.
Pleurocentesis
- Examination of pleural fluid will reveal gastric contents, an elevated amylase, and a low pH (generally <7.4).
Adjunctive upper endoscopy
- Flexible upper endoscopy to confirm negative esophagram findings is controversial.
- While it can be helpful if initial contrast study is negative, it carries the risk of worsening small tears or causing new perforation.