Esophageal Perforation

What happens in esophageal perforation

The esophagus runs from the throat, behind the heart, through the center of the chest (the mediastinum) to the stomach. When its wall is breached, swallowed material, saliva, bacteria and stomach acid leak into the mediastinum, the space around the lungs (pleural space), or the neck. This causes intense inflammation and infection (mediastinitis) that can rapidly lead to sepsis, shock and organ failure.

Causes

Medical procedures (most common)

• Upper endoscopy, especially with dilation of a narrowing (esophageal stricture) or treatment of achalasia
• Placement of tubes such as nasogastric tubes or breathing tubes
• Transesophageal echocardiography
• Surgery in the neck or chest

Boerhaave syndrome

Forceful vomiting or retching causes a sudden rise in pressure inside the esophagus, splitting the wall, usually just above the stomach on the left side. It is classically associated with heavy eating or drinking followed by vomiting. This is different from a Mallory-Weiss tear, which involves only the inner lining and causes bleeding rather than perforation.

Other causes

• Swallowed foreign bodies: fish or chicken bones, dentures, button batteries
• Caustic ingestion: drain cleaners and other strong acids or alkalis
• Trauma: penetrating wounds to the neck or chest, and rarely blunt trauma
• Esophageal cancer and severe infections or ulcers weakening the wall

Symptoms

Symptoms depend on the location and size of the hole and how long ago it happened:

• Severe pain in the chest, upper belly, neck or between the shoulder blades, often sudden
• Painful or difficult swallowing
• Vomiting, sometimes with blood
• Fever and chills
• Fast heart rate and fast breathing
• Shortness of breath if fluid or air enters the chest cavity
• Subcutaneous emphysema: air trapped under the skin of the neck or chest that crackles when pressed
• Neck pain and stiffness with perforations in the neck

The classic combination of vomiting, lower chest pain and air under the skin (Mackler triad) is seen in only a minority, so the condition is often initially mistaken for a heart attack, pancreatitis or a perforated ulcer.

Diagnosis

• CT scan of the chest with oral contrast: the main test. It shows leaked contrast, air outside the esophagus, fluid collections and the location of the hole.
• Contrast swallow study (esophagram): X-rays taken as you swallow a water-soluble contrast.
• Chest X-ray: may show air in the mediastinum, a collapsed lung or fluid around the lung.
• Endoscopy: sometimes used carefully to confirm and treat the perforation.
• Blood tests: white cell count and markers of infection and organ function.

Treatment

Treatment begins immediately:

• Nothing by mouth: no food or drink. Nutrition is given through a feeding tube or IV.
• IV fluids and broad-spectrum antibiotics, plus antifungal medicine in some cases.
• Acid-suppressing medicines.
• Drainage of fluid collections in the chest with chest tubes or surgery.

The approach to closing the hole depends on its size, location, cause, how quickly it was found, and the person's overall health:

• Conservative management: small, contained perforations found early, often after endoscopy, may heal with the measures above and close monitoring.
• Endoscopic treatment: clips, covered stents or vacuum-assisted closure placed through an endoscope.
• Surgery: repair of the hole, drainage and washout of the chest. In severe cases or with underlying cancer, part of the esophagus may need to be removed.

Complications and outlook

Complications include mediastinitis, sepsis, empyema (pus around the lung), fistulas, narrowing of the esophagus and death. Outcomes are much better when treatment starts within 24 hours. Delayed diagnosis substantially increases mortality. Many survivors recover normal swallowing, though some need further procedures.

Prevention

• Chew food thoroughly and be careful with small bones.
• Keep button batteries, magnets and caustic chemicals away from children.
• Report chest pain or fever after any endoscopic procedure promptly.

Frequently asked questions

What causes a perforated esophagus?

Most perforations are caused by medical procedures such as endoscopy, especially when a narrowing is stretched. Others result from forceful vomiting (Boerhaave syndrome), swallowed sharp objects or batteries, caustic chemicals, trauma, or weakening of the wall by cancer.

What are the symptoms of esophageal perforation?

Typical symptoms are sudden, severe chest, neck or upper belly pain, painful swallowing, vomiting, fever, fast breathing and a fast heart rate. Air may leak under the skin of the neck or chest, causing a crackling feeling. Symptoms after an endoscopy need immediate medical attention.

What is Boerhaave syndrome?

Boerhaave syndrome is a spontaneous rupture of the esophagus caused by forceful vomiting or retching. The pressure surge splits the wall, usually low in the esophagus. It causes sudden severe chest pain and is a surgical emergency with a high risk of death if treatment is delayed.

Can esophageal perforation heal on its own?

Small, contained perforations found early, particularly after endoscopy, can sometimes heal with no food or drink by mouth, IV antibiotics and close monitoring in hospital. Larger or delayed perforations usually need stents, endoscopic closure or surgery.