Esophagus 1

Esophagus, Tear Background An esophageal tear is defined as a breach of esophageal wall, whether due to a mucosal: * tear * perforation or rupture

Esophagus, Tear Background Esophageal tears are life-threatening conditions that require prompt diagnosis and emergency treatment Currently, the most common causes of esophageal: * tear * perforation or * Hematoma

are iatrogenic factors

Anatomy recall, esophagus

Esophagus, Tear Background An esophageal tear allows upper GI contents to egress from the esophageal lumen into: ► the soft tissues of the neck ► the mediastinum and pleural space ► the peritoneal cavity and ► possibly multiple sites, depending on the location of the injury

Esophagus, Tear Background Cervical soft tissue infections, mediastinitis, pleuritis, or peritonitis ensue followed by: * systemic sepsis and * death if the condition remains untreated ► Esophageal perforations or tears almost always require surgical correction, though a small and contained esophageal tear is occasionally managed expectantly

Esophagus, Tear Background Esophageal rupture occurs because the esophagus, unlike the rest of the alimentary tract, lacks a serosal layer, which usually contains: * collagen and * elastic fibers The esophageal wall is thus comparatively weaker and may rupture at a lower intraluminal pressure

Esophagus, Tear Background Remember Vomiting is usually the precipitating factor for spontaneous esophageal rupture Survival improves dramatically if the esophageal injury is:

* recognized and * treated within 24 hours of its occurrence

Esophagus, Tear Types of esophageal injuries Boerhaave syndrome Boerhaave description of a case of esophageal rupture associated with forceful retching and vomiting was published in 1724 This clinical syndrome bears his name today

Esophagus, Tear Types of esophageal injuries Boerhaave syndrome Boerhaave syndrome is a transmural perforation of the esophagus Boerhaave syndrome usually is not truly spontaneous However, the term is useful for distinguishing it from iatrogenic perforation, which accounts for 85-90% of cases of esophageal rupture

Esophagus, Tear Types of esophageal injuries Boerhaave syndrome Diagnosis can be difficult because often no classic symptoms are present Approximately one third of all cases are clinically atypical

Esophagus, Tear Types of esophageal injuries Boerhaave syndrome Prompt recognition of this potentially lethal condition is vital to ensure appropriate treatment * Mediastinitis * Sepsis and * Shock frequently are seen late in the course of illness, which further confuses the diagnostic picture

Esophagus, Tear Boerhaave syndrome Pathophysiology: Esophageal rupture in Boerhaave syndrome is postulated to be the result of a sudden rise in intraluminal esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of the cricopharyngeus muscle to relax

Boerhaave syndrome Pathophysiology: The syndrome commonly is associated with overindulgence in food and/or alcohol The most common anatomical location of the in Boerhaave syndrome is at the posterolateral wall of the lower third of esophagus, 2-3 cm proximal to gastroesophageal junction, along longitudinal wall of the esophagus

tear left the the the

Esophagus, Tear Boerhaave syndrome Pathophysiology: The second most common site of rupture is in the: * subdiaphragmatic or * upper thoracic area Frequency Overall, Boerhaave syndrome accounts for 15% of all traumatic rupture or perforation of the esophagus

Esophagus, Tear Boerhaave syndrome Mortality/Morbidity A reported mortality estimate is approximately 35%, making it the most lethal perforation of the GI tract The best outcomes are associated with: 1) early diagnosis and 2) definitive surgical management within 12 hours of rupture

Boerhaave syndrome Mortality/Morbidity If intervention is delayed longer than: ► 24 hours, the mortality rate (even with surgical intervention) rises to higher than 50% ► and to nearly 90% after 48 hours ► Left untreated, the mortality rate is close to 100%

Esophagus, Tear Boerhaave syndrome Race: Cases have been reported in all races and on virtually every continent Sex: The syndrome is described more commonly in males than in females, with ratios ranging from 2:1 to 5:1 Age: It is seen most frequently among patients aged 50-70 years

Esophagus, Tear Types of esophageal injuries Boerhaave syndrome Clinical Presentation History 1) The classic clinical presentation usually consists of repeated episodes of: retching and vomiting typically in a middle-aged man with recent: excessive dietary and alcohol intake

Boerhaave syndrome Clinical Presentation History This is followed by: ► A sudden onset of severe chest pain in the: * lower thorax and * upper abdomen ► The pain may radiate to the: * back or * left shoulder ► Swallowing often aggravates it

Boerhaave syndrome Clinical Presentation History ► Typically, hematemesis is not seen after esophageal rupture, which helps distinguish it from the other Esophagogastrointestinal (EGI) diseases

► Swallowing may precipitate coughing because of communication between the esophagus and the pleural cavity

Boerhaave syndrome Clinical Presentation History

2)

Atypical clinical features sometimes delay a prompt diagnosis and appropriate intervention

► This may result in an increase in: morbidity and mortality Shortness of breath is a common complaint and is due to: pleuritic pain or pleural effusion

Boerhaave syndrome Clinical Presentation Physical Examination The Meckler triad defines the classic presentation It consists of: * vomiting * lower thoracic pain and * subcutaneous emphysema

Boerhaave syndrome Clinical Presentation Physical Examination Presentation may vary depending on the following: The location of the tear The cause of the injury The amount of time that has passed from the perforation to the intervention

Boerhaave syndrome Clinical Presentation Physical Examination ► Patients with cervical esophagus perforation may present with: * neck or * upper chest pain ► Patients with middle or lower esophagus perforation may present with: * interscapular or * epigastric discomfort

Boerhaave syndrome Clinical Presentation Physical Examination If present, subcutaneous emphysema is particularly helpful for confirming diagnosis

► It is seen in 28-66% of patients at initial presentation ► More typically, it is found later

Boerhaave syndrome Physical Examination Other classic findings, as described by Anderson and Barrett, include:

*

tachypnea and

*

abdominal rigidity

►*Tachycardia, *diaphoresis, *fever, and *hypotension are common, particularly as the illness progresses However, these findings are nonspecific

Boerhaave syndrome Clinical Presentation Physical Examination Pneumomediastinum is a very important finding

It may cause a crackling sound upon chest auscultation, known as the Hamman crunch

► This is present in 20% of patients

Boerhaave syndrome Clinical Presentation Physical Examination Later stages of illness may manifest as signs of: * infection and * sepsis Symptoms may include:

* fever * hemodynamic instability and * progressive obtundation .

Boerhaave syndrome Clinical Presentation Physical Examination Establishing a diagnosis in the later stages can be quite difficult because septic complications begin to dominate the clinical picture Early diagnosis is critical

Esophagus, Tear Boerhaave syndrome Differential Diagnosis Aortic Dissection Esophageal Rupture Mallory-Weiss Tear Myocardial Infarction Pancreatitis, Acute Peptic Ulcer Disease Pneumothorax

Esophagus, Tear Boerhaave syndrome Workup Lab Studies Laboratory findings often are nonspecific Patients may present with: leukocytosis and a left shift As many as 50% of patients have a hematocrit value that approaches 50%

Esophagus, Tear Boerhaave syndrome Workup Lab Studies Serum albumin is normal but may be low

Boerhaave syndrome Workup Lab Studies Many patients present with a pleural effusion Thoracentesis with examination of the pleural fluid can aid in diagnosis Undigested food particles and gastric juices usually are found If no gross particles are found, cytology can confirm or exclude their presence

Boerhaave syndrome Workup Lab Studies

Amylase and squamous cells from saliva may be found

Boerhaave syndrome Imaging Studies Upright chest radiograph This is useful in the initial diagnosis because 90% of patients reveal an abnormal finding after perforation The most common finding is a unilateral effusion, usually on the left This corresponds with the fact that most perforations occur in the left posterior aspect of the esophagus

Boerhaave syndrome Imaging Studies Upright chest radiograph Other findings may include: pneumothorax hydropneumothorax pneumomediastinum subcutaneous emphysema or mediastinal widening

Boerhaave syndrome Imaging Studies Upright chest radiograph The V-sign of Naclerio has been described as a chest radiograph finding in as many as 20% of patients

Boerhaave syndrome Imaging Studies Esophagram

This helps confirm the diagnosis

It typically shows extravasation of contrast into the pleural cavity The study outlines the length of the perforation and its location, which aids in the decision of whether to use a thoracic or abdominal surgical approach

Boerhaave syndrome Imaging Studies CT scan It can reveal decisive criteria for diagnosis It localizes collections of fluid for surgical drainage CT scan may not precisely localize the site of perforation Endoscopy Is not commonly used to aid in diagnosis

Boerhaave syndrome Treatment Conservative Surgery

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