Esophageal Injury: Types, Warning Signs and Treatment

Types of esophageal injury

Pill esophagitis

Some medicines irritate the lining if they stick on the way down, especially when taken lying down or with too little water. Common culprits are doxycycline and tetracycline, NSAIDs such as ibuprofen and aspirin, bisphosphonates for osteoporosis, potassium chloride tablets, and iron. Symptoms start hours after the dose: sharp pain on swallowing and pain behind the breastbone. Most cases heal within 1 to 3 weeks once the trigger is stopped. Taking pills upright, with a full glass of water, and staying upright for 30 minutes prevents it.

Tears from vomiting: Mallory-Weiss and Boerhaave

A Mallory-Weiss tear is a split in the lining where the esophagus meets the stomach, usually after repeated vomiting or retching, often linked with alcohol. You may see bright red blood or streaks in vomit. Most stop bleeding by themselves. Endoscopy is used to confirm the tear and to treat it if bleeding continues.

Boerhaave syndrome is a full-thickness rupture of the lower esophagus during forceful vomiting. It causes sudden severe chest or upper belly pain, often with vomiting and crackling under the skin of the neck from leaked air. It is a surgical emergency. See esophageal rupture.

Stuck food and swallowed objects

Food impaction, usually a piece of meat, is the most common cause of a blockage in adults. It often reveals an underlying problem such as a narrowing (esophageal stricture), eosinophilic esophagitis or a ring. If you cannot swallow your saliva, an endoscopy is needed within hours. Do not try to force it down with bread.

In children, swallowed objects such as coins, toys, button batteries and magnets are the main concern. A button battery lodged in the esophagus can burn through the wall within 2 hours, sometimes into major blood vessels. If a child aged 1 year or older swallowed a battery within the last 12 hours and can swallow, the National Capital Poison Center advises giving 2 teaspoons (10 ml) of honey every 10 minutes, up to 6 doses, on the way to the ER. Do not delay travel to do this, and never give honey to babies under 12 months. Two or more magnets can attract through bowel walls and cause perforations.

Chemical (caustic) burns

Swallowing strong alkalis (drain and oven cleaners, lye, some dishwasher products) or acids (toilet cleaners, rust removers) burns the mouth, esophagus and stomach. Alkalis tend to cause deeper burns of the esophagus. Signs include mouth burns, drooling, pain on swallowing, vomiting, hoarseness and breathing difficulty. The absence of mouth burns does not rule out serious esophageal injury.

What to do:

• Call Poison Control at 1-800-222-1222 or 911.
• Do not make the person vomit, and do not give "neutralizing" liquids.
• Rinse the mouth with water. Follow Poison Control's advice before giving anything to drink.

Doctors usually perform an endoscopy within 12 to 48 hours to grade the burn. Severe burns can perforate and often scar into a stricture weeks to months later. The risk of esophageal cancer is raised many years afterward, so long-term follow-up is advised. More on chemical burns.

Perforation from procedures and trauma

Most esophageal perforations happen during medical procedures, especially stretching (dilation) of a narrowing, removal of a foreign body or other endoscopic treatments. Others follow stab or gunshot wounds, blunt chest trauma, or sharp swallowed objects such as fish bones. Air and stomach contents leak into the chest, causing mediastinitis, a dangerous infection around the heart and lungs. Treatment within 24 hours gives the best chance of survival.

How esophageal injury is diagnosed

• Endoscopy: a camera tube that views and can treat the lining, remove stuck food or objects, and stop bleeding.
• CT scan of the neck, chest and abdomen: the best test for suspected perforation, showing leaked air or fluid.
• Contrast swallow: a special X-ray with water-soluble dye that shows leaks.
• X-rays: show swallowed batteries, coins and magnets. A battery shows a "double ring" edge.

Treatment

• Minor lining injuries: stopping the cause, acid-suppressing medicines, soft foods and pain relief.
• Bleeding tears: endoscopic clips, injections or heat therapy if bleeding does not stop.
• Stuck objects and food: endoscopic removal, urgently for batteries, magnets, sharp objects and complete blockages.
• Perforations: no food or drink by mouth, intravenous fluids and antibiotics, and either an endoscopic stent or clip, drainage or surgical repair.
• Strictures after injury: repeated dilation, and sometimes surgery.

Frequently asked questions

What are the symptoms of a damaged esophagus?

Common symptoms include pain or difficulty swallowing, pain behind the breastbone, a feeling of food sticking, vomiting blood, and drooling. Severe injuries such as perforation cause intense chest or neck pain, fever, a fast heart rate and sometimes crackling under the skin of the neck.

How long does it take for an injured esophagus to heal?

Mild injuries such as pill esophagitis and small Mallory-Weiss tears usually heal within days to 3 weeks. Caustic burns can take weeks and may scar into a narrowing over months. Perforations need hospital treatment, and recovery can take several weeks.

Can vomiting tear your esophagus?

Yes. Forceful or repeated vomiting can cause a Mallory-Weiss tear of the lining, which causes blood in vomit and usually heals by itself. Rarely, it causes Boerhaave syndrome, a full rupture of the esophagus that needs emergency surgery.

What should I eat after an esophageal injury?

Follow your doctor's instructions, as some injuries require no food by mouth at first. For lining injuries, cool liquids and soft, moist foods such as yogurt, soup and mashed potatoes are easiest. Avoid alcohol, spicy, acidic and very hot foods, and take any pills upright with plenty of water.

Is food stuck in the esophagus an emergency?

It becomes an emergency if you cannot swallow your saliva, are drooling or have trouble breathing. Food that is stuck but lets saliva pass still needs medical review if it has not cleared within a few hours, because prolonged impaction can damage the wall.