Esophageal Rupture and Perforation

Esophageal perforation and rupture may occur from small penetrations after endoscopy; full-thickness ruptures may follow from a tear or penetration. Presentation, diagnosis, and treatment are variable. The rarity of the diagnosis and variability in clinical presentation often lead to diagnostic and treatment delays. This is especially true of spontaneous perforation, where the clinical suspicion is low. Evaluation for more common medical conditions—such as myocardial infarction, pneumonia, and peptic ulcer disease—usually occurs first. The most severe, traumatic perforations represent 75% of esophageal injuries, with spontaneous rupture of the esophagus less common; however, both are surgical emergencies ( Fig. 8.1 ).

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Rupture and Perforation of the Esophagus.

Greater than 50% of esophageal perforations are iatrogenic, most occurring during endoscopy with dilation, ablation, resection, or endoscopic antireflux procedures. Major causes include barotrauma in 15% from seizure, weightlifting, or Boerhaave syndrome. Foreign body ingestion occurs in 12% of patients and includes objects (e.g., coins, pins) and food (e.g., fish or chicken bones). Trauma may be the cause in 9% and can result from penetration and blunt injury. Intraoperative injury may occur in 2% due to the placement of nasogastric tubes, endotracheal or Sengstaken-Blakemore tubes, and bougies; it may also occur in the course of neck or chest surgery and laparoscopic foregut surgery.

Perforation may result from malignancies in 1% or from inflammatory processes such as Crohn disease and gastroesophageal reflux with ulcers. Infection is always a possibility as well. Caustic alkaline or acid injury may also cause esophageal damage, as may peptic ulcers, pill esophagitis, or esophageal diseases such eosinophilic esophagitis. Approximately 70% of perforations occur on the left side of the esophagus, 20% occur on the right side, and 10% are bilateral.

Esophageal perforation usually occurs at the narrowest areas of the esophagus: the cricopharyngeal muscle, the bronchoaortic constriction, and the esophagogastric junction. Increased intraluminal pressure at these sites along with predisposing conditions of a malignancy, foreign body, or physiologic dysfunction are more likely to lead to rupture of the esophagus.

Perforation of the cervical esophagus through endoscopy is likely in areas of blind pouches, such as a Zenker diverticulum or the pyriform sinus. It is common in elderly persons who have kyphosis and are unable to open their mouths completely because of muscle contracture. The endoscopist is usually immediately aware of the perforation because bleeding occurs, and the anatomy is difficult to discern. Overall, the distal third of the esophagus is the most common site of perforation because it is also the most frequent location for tumors and inflammation. Patients with evidence of a malignancy at the time of esophagogastroduodenoscopy may have as high as a 10% incidence of perforation.

Boerhaave syndrome, or spontaneous rupture of the esophagus, occurs from barotrauma due to violent coughing, vomiting, or weightlifting or from the Heimlich maneuver. A sudden pressure transfer of 150 to 200 mm Hg across the gastroesophageal junction causes damage. Spontaneous rupture occurs in the distal or lower third of the esophagus on the posterolateral wall and results in a 2- to 3-mm linear tear, frequently on the left side of the chest and in alcoholic patients. Penetrating trauma is more likely to cause rupture than blunt trauma. Tearing may occur during misidentification of the retroesophageal space during laparoscopy or with improper passage of a bougie.

With only a sparse connective tissue barrier and no adventitia, the esophagus has limited defenses. Once it is ruptured, infection migrates diffusely and rapidly. The mortality rate from perforation is high because the anatomy of the esophagus enables direct communication with the mediastinum, allowing the entry of bacteria and digestive enzymes and leading to sepsis, mediastinitis, empyema, and multiorgan failure.