Esophageal Perforation

Overview

Esophageal perforation is a tear or hole that goes all the way through the wall of the esophagus, the muscular tube that carries food from the throat to the stomach. When the wall is breached, saliva, swallowed food, stomach acid, and bacteria can leak into the chest cavity (the mediastinum), where they cause rapid, severe inflammation and infection.

This is one of the most serious problems of the digestive tract and is treated as a true emergency. The chest is not designed to tolerate digestive contents, so a delay in care allows infection to spread quickly. With prompt recognition and treatment, however, many people recover, which is why knowing the warning signs matters.

Symptoms

Symptoms usually come on suddenly and become severe over a short time. A classic pattern is intense pain after forceful vomiting or after a procedure on the esophagus.

• Sudden, severe chest pain or pain between the shoulder blades
• Pain when swallowing or inability to swallow
• Difficulty breathing or rapid breathing
• Fever, chills, and a fast heartbeat
• Swelling or a crackling feeling under the skin of the neck or chest (from trapped air)
• Vomiting, sometimes with blood

Anyone with sudden severe chest pain, trouble breathing, or pain after vomiting or a recent procedure should call emergency services right away. This condition can worsen within hours.

Causes

The esophageal wall can be torn from the inside or damaged from the outside. Common causes include:

• Medical procedures: Endoscopy, dilation of a narrowing, or placement of a tube can occasionally injure the wall. This is the most frequent cause.
• Forceful vomiting: A spontaneous rupture from violent retching is called Boerhaave syndrome.
• Swallowed objects or caustic substances: Sharp objects, bones, or swallowed chemicals can burn or pierce the wall.
• Trauma: A blow to the chest, a knife or gunshot wound, or a difficult intubation.
• Underlying disease: A pre-existing problem such as an esophageal stricture, severe inflammation, or esophageal cancer can weaken the wall.

Risk Factors

• Recent endoscopy or esophageal dilation
• Severe or repeated vomiting
• Existing esophageal disease such as ulcers, strictures, or cancer
• Heavy alcohol use, which is linked to forceful vomiting
• Swallowed foreign objects or corrosive substances
• Chest trauma

Diagnosis

Because this is an emergency, doctors move quickly to confirm the diagnosis and find the location of the tear.

• Imaging: A chest X-ray may show air or fluid in the chest. A CT scan of the chest gives a clearer picture and is often the test of choice.
• Contrast swallow study: Drinking a safe contrast liquid while X-rays are taken can show where the leak is.
• Endoscopy: In selected cases a camera is used to view the tear directly.
• Blood tests: To check for signs of infection and how the body is coping.

Treatment

Treatment depends on how large the tear is, where it is, and how soon it is found. Care almost always takes place in the hospital, often in intensive care.

• Stopping oral intake: The person is kept from eating or drinking so nothing leaks through the tear, and nutrition is given through a vein or a feeding tube.
• Antibiotics: Strong intravenous antibiotics treat and prevent infection in the chest.
• Draining the chest: Tubes may be placed to drain leaked fluid and infection from the mediastinum, which can lead to mediastinitis if not controlled.
• Stents or clips: A covered stent or endoscopic clip can sometimes seal a smaller tear.
• Surgery: Larger or later-recognized tears often need an operation to repair or, in severe cases, remove part of the esophagus.

Prevention

• Have endoscopic procedures done by experienced teams, and tell your provider about any swallowing problems beforehand
• Seek treatment for conditions that narrow or weaken the esophagus
• Avoid swallowing non-food objects or corrosive chemicals, and keep such substances away from children
• Limit heavy alcohol use, which is linked to forceful vomiting
• Get prompt care for severe or repeated vomiting

When to See a Doctor

Esophageal perforation is a medical emergency. Call emergency services or go to the nearest emergency department immediately if you have:

• Sudden, severe chest or upper back pain, especially after vomiting or a recent esophageal procedure
• Pain when swallowing or a sudden inability to swallow
• Difficulty breathing
• Fever with a fast heartbeat after the above symptoms
• A crackling feeling under the skin of the neck or chest

Do not wait to see if the pain passes. Early treatment greatly improves the chance of recovery.

Related Topics

Frequently Asked Questions

References

1. Mayo Clinic. Boerhaave syndrome and esophageal rupture.
2. MedlinePlus, U.S. National Library of Medicine. Esophageal perforation.
3. National Library of Medicine, StatPearls. Esophageal Perforation.
4. American College of Gastroenterology. Esophageal conditions.