•:• CASE 3

A 43-year-old man presents to the emergency department with severe abdominal pain and substernal chest pain. The patient’s symptoms began approximately 12 hours earlier after he returned from a party where he consumed a large amount of alcohol that made him ill. Subsequently, he vomited several times and then went to sleep. A short time thereafter, he was awakened with severe pain in the upper abdomen and substernal area. His past medical history is unremarkable, and he is currently taking no medications. On physical examination, the patient appears uncomfortable and anxious. His temperature is 38.8°C (101.8°F), pulse rate 120/mm, blood pressure 126/80, and respiratory rate 32/mm. The findings from an examination of his head and neck are unremarkable. The lungs are clear bilaterally with decreased breath sounds on the left side. The cardiac examination reveals tachycardia and no murmurs, rubs, or gallops. The abdomen is tender to palpation in the epigastric region, with involuntary guarding. The results of a rectal examination are normal. Laboratory studies reveal that his white blood count is 26,000/mm and that his hemoglobin, hematocrit, and electrolyte levels are normal. The serum amylase. bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase values are within normal limits. A 12-lead electrocardiogram shows sinus tachycardia. His chest radiograph reveals moderate left pleural effusion, a left pneumothorax, and pneumomediastinum.

• What is the most likely diagnosis?

• What is your next step?

ANSWERS TO CASE 3: Esophageal Perforation

Summary: A 43-year-old man presents with a spontaneous thoracic esophageal perforation (Boerhaave syndrome). The patient has a left pneumothorax and exhibits a septic process from the mediastinitis.

• Most likely diagnosis: A spontaneous esophageal rupture (Boerhaave syndrome).

• Next step: Management of the airway, breathing, and circulation

(ABCs), including the placement of a left chest tube, fluid resuscitation, and the administration of broad-spectrum antibiotics, followed by a

water-soluble contrast study of the esophagus.

Analysis

Objectives

I. Recognize the clinical settings, early signs and symptoms, and complications of esophageal perforation.

2. Understand the diagnostic and therapeutic approach to a suspected esophageal perforation.

Considerations

This patient’s clinical presentation is classic for a spontaneous esophageal perforation; however, delay in diagnosis and treatment can still occur because many physicians do not have extensive experience in the evaluation and treatment of this problem. Maintaining a high index of suspicion and pursuing an early diagnosis and early treatment are essential.

APPROACH TO SUSPECTED ESOPHAGEAL

PERFORATION

Esophageal perforation remains a surgical emergency. A delay in diagnosis leads to increased morbidity and mortality: therefore, a high index of suspicion should be maintained. Most esophageal perforations are iatrogenic and occur during a diagnostic or therapeutic procedure. Spontaneous esophageal perforation, also referred to as Boerhaave syndrome, accounts for approximately 15% of all causes of esophageal perforation.

The development of an acute onset of chest pain after an episode of vomiting is typical of Boerhaave syndrome. Other symptoms that may be present include shoulder pain. dyspnea. and midepigastric pain. Findings from a physical examination, screening radiographs, and laboratory results depend on (I) the integrity of the mediastinum, (2) the location of the perforation. (3) and the time elapsed since the perforation. Seventy-five percent of patients present with a pleural effusion indicating disruption of the mediastinal pleura. Contamination of the mediastinum with esophageal luminal contents often leads to mediastinitis and chest pain. A delay in treatment leads to sepsis with signs of systemic infection (tachycardia, fever, and leukocytosis). Perforation into the mediastinum leads to pneumomediastinum that can be seen on a chest radiograph and subcutaneous emphysema that can be demonstrated by physical examination. Because most spontaneous esophageal ruptures occur in the distal third of the esophagus above the GE junction, two thirds of patients present with a left pleural effusion. The time from perforation to the time of diagnosis is of paramount importance to the ultimate outcome (see Table 3—1).

Diagnosis

The best initial diagnostic test for an esophageal rupture is a water- soluble contrast esophagograni, which identifies perforation in 90% of cases. Water-soluble contrast is preferred during the initial examination because it causes less mediastinal irritation than barium if a large leak is discovered. Water-soluble contrast (Gastrografin) esophagram should be obtained with the patient in the right lateral decubitus position to improve its diagnostic sensitivity, and if no leak is visualized, barium contrast may be given to conhirm the absence of a leak. Once perforation is diagnosed. the initial treatments include prompt resuscitation (directed toward airway, breathing, and circulation—the ABCs). antibiotics therapy, and preparation for operative therapy. The treatment principles for spontaneous esophageal perforation include surgical drainage, debridement, repair, and diversion (Figurc 3—1).

Table 3—1

CLINICAL PROGRESSION OF SPONTANEOUS

ESOPHAGEAL PERFORATION

SIGN OR SYMPTOM

TIME OF OCCURRENCE

COMMENTS

Chest pain

immediate, persistent

Most common presenting symptom; less specific are shoulder and abdominal pain.

Subcutaneous emphysema

I h after perforation

Occurs more frequently with iatrogenic cervical perforation; may not be present with lower esophageal perforation.

Pleural effusion on chest radiograph

May be immediate or late (>6 h)

Occurs in 75% of cases; most often on left side (66%) but may occur on right side (20%).

Fever, leukocytosis

>4 h

Sepsis from mediastinitis.

Death

Diagnosis made <24 h. 15%

Diagnosis made >24 h, >40%

Outcome is dependent on early diagnosis and treatment.

Comprehension Questions

L3.11 Which of the following is the most common cause of esophageal perforation?

A. Trauma

B. latrogenic (endoscopy)

C. Spontaneous rupture (Boerhaave syndrome)

D. Caustic injury

13.21 Which of the following is the most sensitive diagnostic examination for diagnosing esophageal perforation?

A. A barium esophagogram

B. A Gastrografin esophagogram

C. Esophagoscopy

D. Computed tomography

[3.3] Which of the following is the most important factor that determines the outcome in esophageal perforation?

A. The size of the perforation

B. Whether a meal has been ingested recently

C. The duration between the event and the corrective surgery

D. Leukocytosis

[3.4] After eating some stale pizza, a 21 -year-old college student presents to the emergency department with a 24-hour history of nausea, vomiting. and severe chest pain. An esophageal perforation is diagnosed by a contrast study, with the best clinical impression of its onset occurring approximately 12 hours previously. Which of the following is the best treatment?

A. Primary surgical repair

B. Endoscopic repair

C. Gastrostomy tube and observation

D. Continued observation for spontaneous healing

Answers

[3.1] B. Diagnostic endoscopy is associated with the risk of cervical esophageal perforation. and therapeutic endoscopy (pneumatic dilatation) is most commonly associated with pertbration of the distal esophagus.

13.2] A. Barium study is the most sensitive diagnostic method: however, it is associated with barium-associated mediastinitis and peritonitis. A Gastrografin (water-soluble) esophagogram is the most common diagnostic study that is >90% accurate in identifying a perforation.

[3.3] C. The outcome to an esophageal perforation is directly related to the elapsed time between the perforation and the treatment.

13.41 A. Primary esophageal repair is generally performed when the perforation is <24 hours in duration. In patients in good physiologic condition, surgical repair is generally used regardless of the duration of perforation.

CLINICAL PEARLS

Spontaneous esophageal perforation should be suspected in a patient with chest pain after vomiting, subcutaneous emphysema found on physical examination, and left-sided effusion demonstrated Ofl a chest radiograph.

A high index of suspicion is needed because a delay in diagnosis directly compromises patient outcome.

Most spontaneous esophageal ruptures occur in the distal third of the esophagus.

Most iatrogenic esophageal perforations are associated with endoscopy.