Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 27
Esophageal Rupture
ChristopherJ.Rees, CharlesV.Pollack,Jr., andVictoriaG.Riese
Name andSynonyms
Esophageal Rupture
• Esophageal Perforation, Boerhaave’s Syndrome
Incidence/Epidemiology
• Esophageal rupture is a rare but life-threatening event.
• Current mortality of 30 %.
• There are many causes of esophageal rupture (described below). Iatrogenic
causes are the most common, accounting for about half of all cases. Classic
Boerhaave’s syndrome accounts for another 15 %, foreign bodies for 14 %,
trauma (penetrating, blunt, caustic ingestion) for 10 %, and other miscellaneous causes for the remainder of cases seen.
C. J. Rees
Emergency Department, Pennsylvania Hospital, Philadelphia, PA, USA
C. V. Pollack,
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_27
Jr. ()
405© Springer Nature Switzerland AG 2019
406
C. J. Rees et al.
Differential Diagnosis
• Esophageal rupture usually causes acute onset of chest pain, so all the causes
of acute chest pain need to be considered in the differential. These include;
acute coronary syndrome, aortic dissection, pulmonary embolism, pneumonia, pneumothorax, other intra-abdominal catastrophes, amongst others.
• Esophageal rupture has many causes. Usually the history will lead to recognition of the cause of the rupture once identied.
Pathophysiology andEtiology
• Rupture of the esophagus allows for the direct contamination/communication
of esophageal contents into the mediastinum. The esophagus has no serosal
mucosal covering, so there is no anatomic mechanism for containment. The
parietal pleura is very thin and weak, so the local inammatory response
allows for easy disruption of the parietal pleura and passage of contents into
the pleural space.
• The left, posterior, distal esophagus just above the esophagogastric junction is
the weakest point in the esophagus and the most common place for spontaneous rupture and rupture from gastrointestinal endoscopic procedures.
• Complications from tracheal and pharyngeal procedures may lead to rupture
of the cervical esophagus at the level of the cricopharyngeal muscle just distal
to the esophageal introitus, an anatomic narrowing point of the esophagus.
Cervical ruptures often are better localized and not as serious as distal
ruptures.
• There are multiple causes of esophageal rupture.
• Iatrogenic, which is the most common, accounting for about 50 % of cases
• Esophageal rupture complicates about 0.2–1 % of endoscopies. It is
more likely in the setting of pre-existing esophageal disease such as
caustic burns, tumors, eosinophilic esophagitis, and other causes of
esophageal scarring.
• Esophageal dilatation.
• Endotracheal procedures/intubations, and with esophageal obturator
airway placement.
• Spontaneous “Boerhaave’s syndrome”
• Causes about 15 % of all cases.
• First described by Boerhaave in the early 1700s.
• Very high mortality if not recognized early. The forces required to
rupture the esophagus also force the spread of esophageal contents
throughout the mediastinal space, leading to massive mediastinal
contamination.
27 Esophageal Rupture
• The usual site of perforation is the distal esophagus in the left posterior
region, just above the gastroesophageal junction.
• Usually occurs after episodes of sudden, forceful vomiting (about 75 %
of these cases), but also may occur after severe coughing, straining,
seizures, and childbirth (25 % of cases). Therefore, 25 % of cases do not
have the typical history of forceful vomiting.
• A history of alcoholism, recent heavy drinking, and/or overindulging in
food is found in most of the cases due to forceful vomiting.
• Foreign bodies
• Cause 10 % of esophageal perforations.
• Usually from pills, batteries, buttons.
• Caused by either direct laceration or pressure or chemical necrosis.
• Usually occurs at either the cervical or lower esophagus.
• Trauma
• Causes about 10 % of cases.
• May be from caustic (alkali or acid) burns, penetrating trauma, or blunt
trauma.
• Perforation more likely from alkali burns than acid burns.
• Penetrating wounds to the neck, chest, and abdomen associated with
only about a 0.5 % incidence of esophageal perforation.
• Often overlooked initially as more obvious injuries are treated.
• Blunt trauma is a very rare cause.
• Miscellaneous causes (remaining 15 %)
• Esophageal tumors, esophageal disease (achalasia, Barrett’s esophagus,
eosinophilic esophagitis), infectious (rare), aortic pathology (aortic
aneurysm, aberrant right subclavian artery).
407
Presentation
Typical/“Classic”
• Acute onset of severe, constant, sharp, substernal chest pain immediately following an appropriate procedure or an episode of forceful vomiting. Pain is
often pleuritic and radiates in an esophageal pattern (neck into chest and
upper abdomen). Pain often worsens with swallowing.
• Usually the patient appears ill and uncomfortable. He or she also may complain of shortness of breath and be diaphoretic.
• If the patient presents early in the course, physical exam ndings may be
normal.
• If presenting 1–2 hours into the course, the patient may appear septic, with
fever, tachycardia, hypotension, and hypoxia.
408
• “Hamman crunch”: crunching sound heard on auscultation during systole as
the result of air in the mediastinum surrounding the pericardium.
• Classically described subcutaneous emphysema (feeling of crunchiness
[crepitus] under skin due to air tracking through subcutaneous tissues) in neck
is present in only about 25 % at time of presentation.
• Chest x-ray (CXR) may be normal early in course, but over time pneumomediastinum, left more often than right pleural effusion, pneumothorax, hydropneumothorax, and/or a widened mediastinum may develop. CXR also may
demonstrate subcutaneous air.
C. J. Rees et al.
Atypical
• About one-third of cases will present atypically.
• May present as back pain only.
• Remember that about 25 % of patients with spontaneous esophageal rupture
do not give a history of forceful vomiting.
• Many of the classically described physical and radiologic ndings may not
develop until several hours into the clinical course, so a high index of suspicion must be maintained by the treating physician.
• Pneumomediastinum is demonstrated in only about 40 % on plain CXR, even
well into the clinical course.
Primary Differential Considerations
• Patients who present with signs and symptoms consistent with esophageal
rupture also should be evaluated for these differential diagnoses:
• Acute coronary syndrome
• Aortic dissection
• Peptic ulcer disease
• Acute pancreatitis
History andPhysical Exam
Findings That Conrm Diagnosis
• Esophageal rupture is a rare disease, and a high index of suspicion must be
maintained by the treating physician.
• CT is the most common conrmatory study.
27 Esophageal Rupture
• Contrast esophagoscopy and endoscopy also may be used, but less commonly.
• Endoscopy may be falsely negative.
• The combination of contrast esophagoscopy and endoscopy approaches 100
% sensitivity for diagnosis.
Factors That Suggest Diagnosis
• The development of severe chest or upper abdominal pain after an ENT or GI
procedure, after an episode forceful vomiting, after penetrating trauma, or in
a patient with known esophageal disease should suggest the diagnosis, and a
high index of suspicion should be maintained by the treating physician.
• Finding a pneumomediastinum on CXR in the appropriate clinical setting (s/p
procedure, or after forceful vomiting) makes the diagnosis likely enough that
appropriate treatment can proceed while conrmation is sought.
• It is important to remember that pneumomediastinum takes 1–2 hours to
develop, especially in perforation of the lower esophagus, so its absence does
not exclude the diagnosis.
• Pneumomediastinum may be present in only about 40 % of cases.
• Other suggestive ndings on CXR include pleural effusions (left-sided more
common than right), pneumothorax, hydropneumothorax, subcutaneous
emphysema, or pneumoperitoneum.
409
Factors That Exclude Diagnosis
• The nding of another cause for the acute chest pain (e.g., acute myocardial
infarction, aortic dissection) essentially excludes the diagnosis.
• Radiographic studies may all be normal early (rst 1-4 hours) in the course of
the disease, so in an appropriate clinical setting, suspicion must be maintained
even if initial studies are unrevealing.
Ancillary Studies
Laboratory
• There are no laboratory tests that are specic to the diagnosis.
• Patients often manifest laboratory values consistent with an acute, severe,
infectious, or inammatory condition, such as leukocytosis, acidosis, or elevated
lactate.
410
C. J. Rees et al.
Imaging
• The plain CXR often is normal early in the disease course.
• Classically, the CXR may show multiple ndings (alone or in combination):
• Pneumomediastinum (seen in 40 %) with or without subcutaneous
emphysema
Chest X-ray showing pneumomediastinum. [From article: Pneumomediastinum
from nasal insufation of cocaine. International Journal of Emergency Medicine.
2010 Dec;3(4):435–7. https://doi.org/10.1007/s12245-010-0205-9, at http://link.
springer.com/article/10.1007%2Fs12245-010-0205-9; by Brian T. Kloss, Claire
E.Broton, Elliot Rodriguez, © Springer-Verlag London Ltd 2010; licensed under
Creative Commons Attribution License BY 2.0
http://creativecommons.org/
licenses/by/2.0] Caption adapted from original
• Left-sided pleural effusion
27 Esophageal Rupture
411
CXR demonstrating a left-sided pleural effusion. [Kohler JA, Ellis AR.LibmanSacks Endocarditis in Pediatric Patient With Systemic Lupus Erythematosus.
Pediatric Cardiology. 2012 Dec;33(8):1466–8.]
• Pneumothorax or hydropneumothorax
• Widened mediastinum
• CT scan of the chest often demonstrates the esophageal perforation and is
more sensitive than CXR for detecting mediastinal air. Chest CT is the diagnostic study of choice.
412
C. J. Rees et al.
a Chest radiography demonstrating pneumomediastinum (arrows). There were no
inltrates, atelectasis, or pleural effusion apart from the subcutaneous emphysema.
b Esophagography with water-soluble contrast medium depicted a small but visible
right-sided submucosal tear representing a contained esophageal perforation
(arrow). No contrast medium extravasation through the esophagus was seen. c
Nonenhanced CT demonstrated high attenuation of the supradiaphragmatic wall at
a typical site, suggesting an intramural hematoma. c, d Nonenhanced and contrastenhanced CT revealed an esophageal wall thickening which is a nonspecic nding.
e–g CT at the level of the thyroid gland showed extensive pneumomediastinum and
subcutaneous emphysema. Intraspinal air collections were seen at multiple levels in
the spinal canal as visualization of air tracks (*). In addition to a large quantity of
air in the anterior and posterior mediastinum, local periesophageal extraluminal air
collections were observed indicating extraluminal complications of Boerhaave's
syndrome. CT scan depicted air tracks (arrows) extending from the esophagus into
the anterior lower mediastinum (g). [Radiological ndings in Boerhaave’s syndrome- Springer. [cited 2015 May 19]; Available from: http://link.springer.com/art
icle/10.1007%2Fs10140-002-0264-1/fulltext.html] Caption adapted from original
• Contrast esophagoscopy also may demonstrate the esophageal defect. It
should be performed initially with a water-soluble contrast agent
(Gastrografn), as barium-containing contrast agents, if extruded into the sur-
27 Esophageal Rupture
413
rounding tissues, may incite an inammatory response. However, water-soluble contrast has a higher false-negative rate, so a negative water-soluble study
should then be conrmed by a barium contrast study if the clinical suspicion
remains high.
Water-soluble contrast radiograph of a patient with a distal esophageal perforation.
The white arrows indicate free air in the mediastinum; the black arrow indicates
extravasation of esophageal contrast. [Sánchez-Pernaute A, Aguirre EP, Talavera P,
Valladares LD, de la Serna JP, Mantilla CS, de León AR, Torres A.Laparoscopic
approach to esophageal perforation secondary to pneumatic dilation for achalasia.
Surgical Endoscopy. 2009 May;23(5):1106–9.] Caption from original
• Esophagogastroduodenoscopy (EGD, upper endoscopy) also can directly
demonstrate the esophageal defect. However, endoscopy may also miss a
small defect. The combination of contrast esophagoscopy and endoscopy
approaches 100 % sensitivity for the diagnosis.
414
Boerhaave syndrome. Perforation site was observed in the left side of the esophagus. [Park JM.Miscellaneous Esophageal Diseases. In: Chun HJ, Yang S-K, Choi
M-G, editors. Clinical Gastrointestinal Endoscopy [Internet]. Berlin, Heidelberg:
Springer Berlin Heidelberg; 2014 [cited 2015 May 19]. p.87–98. Available from:
http://link.springer.com/10.1007/978-3-642-35626-1_7] Caption from original
C. J. Rees et al.
Special Populations
Age
• Esophageal rupture is slightly more common inmiddle-aged and older
populations.
Co-morbidities
• Esophageal rupture is associated with chronic alcohol use and with other
esophageal diseases that cause strictures or scarring of the esophagus.
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Consideration of the diagnosis is the critical step. It also is critical to continue
to consider the diagnosis, as physical and radiographic ndings may take several hours to develop after the rupture.
Mimics
• Anything that causes acute chest or upper abdominal pain can mimic esophageal rupture. These include but are not limited to acute myocardial infarction,
pulmonary embolism, aortic dissection, spontaneous pneumothorax, perforated
peptic ulcer, pancreatitis, acute cholecystitis, and mesenteric thrombosis.