Oesophageal rupture

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Diagnosis

Oesophageal rupture can be difficult to diagnose on clinical grounds, although the diagnosis after the commonest presentation due to instrumentation of the oesophagus, should be helped by a high index of suspicion in the context of this history. You may also suspect in spontaneous cases with Mackler's triad or surgical emphysema, particularly of the mediastinum. Chest x-ray may be unhelpful. CT of the thorax is usually diagnostic for large ruptures but radiological contrast swallows and endoscopy may be necessary to make the diagnosis with small ruptures.

Causes

Traumatic

  • During upper G/I endoscopy or procedures
    • Dilation oesophageal stricture
    • Oesopageal obturator airway[1]
    • Transoesophageal echocardiography (TOE)[2]
  • Oesophageal foreign bodies ingestion
  • Thoracic trauma - can be relatively minor

Pathological

Spontaneous

Known as Boerhaave's syndrome.

LogoKeyPointsBox.pngMackler's Triad
  • vomiting
  • lower thoracic pain
  • subcutaneous emphysema.

Spontaneous transmural rupture of the lower oesophagus, usually as a result of forceful vomiting. Rupture of the oesophagus allows gastric content to enter the mediastinum and pleural spaces, which may lead to surgical emphysema, empyema and over-whelming sepsis. Mackler's triad describes the vomiting, lower thoracic pain and subcutaneous emphysema but the triad can happen without oesophageal perforation[3]

Mortality is high. Surgical repair in most cases. Endoscopic treatment using covered, self-expanding stents has been employed successfully in several cases[4][5] although late aorto-oesophageal fistula has been described.[6]

First described in 1724, the diagnosis having been observed in 1723 at the post-mortem of Baron Jan von Wassenaar, the Grand Admiral of the Dutch naval fleet.

Management

It can be equally difficult to manage if more than a minor perforation or detected more than a day after the event, although good outcomes have been reported after prolonged ITU stay even in the elderly with late presentations. Early reinforced primary surgical repair (typically) has the best outcome[7] but with iatrogenic perforation good results have been reported with stents[8][9]. Nonoperative management with antibiotics and parenteral nutrition is particularly successful for limited oesophageal injuries. Other pathology can influence outcome.

Outcome

Mortality rates vary from 10 to 40% in published series, and tend to be lower recently but this might be due to the increasing proportion of iatrogenic cases, although techniques such as stenting might benefit patients not fit for other surgical interventions.

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