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27 Esophageal Rupture
Time-Dependent Interventions
• Early diagnosis is important. Time is critical in decreasing morbidity and
mortality. If primary closure of the defect occurs within the rst 24 hours,
there is 80–90 % survival. If repair occurs greater than 24 hours after rupture,
survival falls below 50 % and may reach 30 %.
• Any patient with hemodynamic instability should be resuscitated, as would
any patient in shock.
Overall Principles ofTreatment
• Rapid resuscitation with intravenous uids, empiric broad-spectrum antibiotics, and appropriate management of complications such as pneumothorax or
hydropneumothorax should begin as appropriate, even if the diagnosis is not
certain.
• Early primary surgical repair of the defect is denitive treatment. Some contained cervical esophageal ruptures may be managed conservatively and
nonoperatively.
415
Disease Course
• Esophageal rupture may be rapidly fatal if not identied and treated early.
• Patients often present in extremis or have a rapidly progressive course.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
ASGE Standards of Practice Committee, Ben-Menachem T, Decker GA, Early DS,
Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO,
Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN,
Dominitz JA, Cash BD.Adverse events of upper GI endoscopy. Gastrointest
Endosc. 2012 Oct;76(4):707-18. https://doi.org/10.1016/j.gie.2012.03.252.
PMID: 22985638. http://www.ncbi.nlm.nih.gov/pubmed/22985638 **
416
C. J. Rees et al.
Review
Nirula R. Esophageal perforation. Surg Clin North Am. 2014 Feb;94(1):35-41.
https://doi.org/10.1016/j.suc.2013.10.003. PMID: 24267495. http://www.ncbi.
nlm.nih.gov/pubmed/24267495 **
Blencowe NS, Strong S, Hollowood AD.Spontaneous oesophageal rupture. BMJ.
2013 May 31;346:f3095. https://doi.org/10.1136/bmj.f3095. PMID: 23729218.
http://www.ncbi.nlm.nih.gov/pubmed/23729218 **
Biancari F, D'Andrea V, Paone R, Di Marco C, Savino G, Koivukangas V, Saarnio J,
Lucenteforte E. Current treatment and outcome of esophageal perforations in
adults: systematic review and meta-analysis of 75 studies. World J Surg. 2013
May;37(5):1051-9. https://doi.org/10.1007/s00268-013-1951-7. PMID:
23440483. http://www.ncbi.nlm.nih.gov/pubmed/23440483
Gomez-Esquivel R, Raju GS.Endoscopic closure of acute esophageal perforations.
Curr Gastroenterol Rep. 2013 May;15(5):321. https://doi.org/10.1007/s11894-
013-0321-9. PMID: 23558969. http://www.ncbi.nlm.nih.gov/pubmed/23558969
Carrott PW Jr, Low DE.Advances in the management of esophageal perforation.
Thorac Surg Clin. 2011 Nov;21(4):541-55. https://doi.org/10.1016/j.thor-
surg.2011.08.002. PMID: 22040636. http://www.ncbi.nlm.nih.gov/pubmed/
22040636 **
Søreide JA, Viste A.Esophageal perforation: diagnostic work-up and clinical deci-
sion-making in the rst 24 hours. Scand J Trauma Resusc Emerg Med. 2011 Oct
30;19:66. https://doi.org/10.1186/1757-7241-19-66. PMID: 22035338. http://
www.ncbi.nlm.nih.gov/pubmed/22035338 **
Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgical, endoscopic
and medical management strategies. Curr Opin Gastroenterol. 2010
Jul;26(4):379- 83. https://doi.org/10.1097/MOG.0b013e32833ae2d7. PMID:
20473156. http://www.ncbi.nlm.nih.gov/pubmed/20473156
Butler KH, Swencki SA.Chest pain: a clinical assessment. Radiol Clin North Am.
2006 Mar;44(2):165-79, vii. PMID: 16500201. http://www.ncbi.nlm.nih.gov/
pubmed/16500201 **
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Esophageal Perforation”[Mesh] OR “esophageal perforation” OR “esophageal
rupture”
Chapter 28
Esophagitis
CharlesV.Pollack,Jr., RichardM.Cantor, andVictoriaG.Riese
Name andSynonyms
Esophagitis
Incidence/Epidemiology
• Esophagitis has been implicated as the cause of chest pain in 20–60 % of
patients with chest pain not having an acute myocardial infarction.
Differential Diagnosis
• Esophagitis may cause acute chest pain, so the initial differential diagnostic
considerations include all the acute causes of chest pain.
• Once the esophagus is believed to be the source of the chest pain, the differential diagnosis may focus on the causes of acute esophagitis, including
inammatory and infectious esophagitis, each of which has multiple causes.
C. V. Pollack,Jr. ()
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
R. M. Cantor
Department of Emergency Medicine and Pediatrics, State University of NewYork Upstate
Medical University, Syracuse, NY, 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_28
417© Springer Nature Switzerland AG 2019
418
C. V. Pollack, Jr. et al.
Pathophysiology andEtiology
• The nal common pathway of pathophysiology is inammation of the
esophageal mucosa. The pathologic changes may progress to include
inammation and ulceration of both the mucosal and muscular layers of
the esophagus. Both may lead to permanent scarring with strictures and
narrowing of the esophagus.
• This inammation may result from multiple insults:
• Inammatory:
• The best example is severe gastroesophageal reux leading to
inammation, ulceration, scarring, and strictures.
• “Pill” esophagitis results from pills remaining in contact with the
esophageal mucosa. The most common location for pills to get stuck
is at the level of the aortic arch, an anatomic narrow point in the
esophagus. This may occur with any medication, but the most commonly implicated are nonsteroidal drugs; potassium tablets; antibiotics, such as clindamycin, doxycycline, and tetracycline; and
bisphosphonates. Pill esophagitis usually causes dysphagia and odynophagia in addition to chest pain. Risk factors for the development
of pill esophagitis include poor pill-taking practices, such as incorrect head position and insufcient water intake with the medication;
swallowing of large tablets; and the extremes of age.
Pill-induced esophagitis. (a) Three days after ingestion of an unknown medication,
a small and a neighboring, large well-demarcated ulcer with intact surrounding
mucosa are noted at mid-esophagus. (b) Scar change of the ulcer after 2 months
[Park KS.Infectious and Noninfectious Esophagitis. In: Chun HJ, Yang S-K, Choi
M-G, editors. Clinical Gastrointestinal Endoscopy [Internet]. Berlin, Heidelberg:
28 Esophagitis
419
Springer Berlin Heidelberg; 2014 [cited 2015 May 14]. p.17–30. Available from:
http://link.springer.com/10.1007/978-3-642-35626-1_3] Caption from original
• Eosinophilic esophagitis. Caused by sequestration and localization of eosinophils within the esophageal mucosa, leading to inammation and narrowing
of the esophageal lumen, with subsequent brosis and scarring. Usually
causes dysphagia and odynophagia, and is a common cause of esophageal
food impaction. Believed to be the result of an allergic response within the
esophageal mucosa.
Eosinophilic esophagitis. (a) Linear furrows, (b) multiple rings [Park KS.Infectious
and Noninfectious Esophagitis. In: Chun HJ, Yang S-K, Choi M-G, editors. Clinical
Gastrointestinal Endoscopy [Internet]. Berlin, Heidelberg: Springer Berlin
Heidelberg; 2014 [cited 2015 May 14]. p. 17–30. Available from: http://link.
springer.com/10.1007/978-3-642-35626-1_3] Caption from original
• Corrosive esophagitis. Occurs after alkali (or less likely, acid) ingestion, with
initial inammation and ulceration and subsequent scarring and stricture
formation.
• Radiation esophagitis. A long-term sequela of mantle radiotherapy for
cancer.
• Infectious: Infectious esophagitis usually is associated with underlying immunosuppression (such as from HIV, cancer, severe diabetes). Diagnosing infectious esophagitis in an otherwise healthy patient should prompt a search for
underlying immunosuppression.
• Candida albicans is the most common cause.
420
C. V. Pollack, Jr. et al.
Candida esophagitis. (a) Coexisting pharyngeal lesions help to diagnose Candida
esophagitis. (b) Multiple white plaques. (c) Diffuse membranous white material. (d)
Atypical lesions which resemble herpetic esophagitis [Park KS. Infectious and
Noninfectious Esophagitis. In: Chun HJ, Yang S-K, Choi M-G, editors. Clinical
Gastrointestinal Endoscopy [Internet]. Berlin, Heidelberg: Springer Berlin
Heidelberg; 2014 [cited 2015 May 14]. p. 17–30. Available from: http://link.
springer.com/10.1007/978-3-642-35626-1_3] Caption from original
• Viral causes include cytomegalovirus and herpes simplex virus.
28 Esophagitis
421
CMV esophagitis. (a) Longitudinal deep ulcer, (b) multiple shallow ulcers mimicking herpes esophagitis [Park KS. Infectious and Noninfectious Esophagitis. In:
Chun HJ, Yang S-K, Choi M-G, editors. Clinical Gastrointestinal Endoscopy
[Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 2014 [cited 2015 May
14]. p.17–30. Available from:
http://link.springer.com/10.1007/978-3-642-35626-
1_3] Caption from original
Herpes esophagitis. (a) Multiple vesicular lesions, (b) shallow ulcers with prominent demarcation, (c) large ulcer formation by conuence of small ulcers [Park
KS.Infectious and Noninfectious Esophagitis. In: Chun HJ, Yang S-K, Choi M-G,
editors. Clinical Gastrointestinal Endoscopy [Internet]. Berlin, Heidelberg: Springer
Berlin Heidelberg; 2014 [cited 2015 May 14]. p.17–30. Available from: http://link.
springer.com/10.1007/978-3-642-35626-1_3] Caption from original
Presentation
Typical/“Classic”
• Chest pain, often described as burning. There is no historical or examination feature
sensitive or specic enough to exclude cardiac causes of chest pain; therefore, a
cardiac workup should be performed before or during evaluation for esophagitis.
422
• Certain symptoms may be helpful if present:
• Odynophagia: pain with swallowing or pain exacerbated by swallowing
• Dysphagia: difculty swallowing. It may be described as a sensation of
food or liquid getting stuck.
C. V. Pollack, Jr. et al.
Atypical
• Any complaint of chest pain may be caused by esophagitis, so there is no typical or atypical presentation.
Primary Differential Considerations
Early in the evaluation of patients with symptoms of esophagitis, consider the following important differential diagnoses:
• Acute coronary syndrome
• Aortic dissection
• Acute pericarditis
• Pneumothorax
• Pleurisy
• Pneumonia
• Esophageal rupture
• Peptic ulcer disease
History andPhysical Exam
Findings That Conrm Diagnosis
• The only ndings that can completely conrm the diagnosis are typical ndings on esophagogastroduodenoscopy (EGD/endoscopy).
Factors That Suggest Diagnosis
• Chest pain associated with pain with swallowing (odynophagia) and/or difculties swallowing (dysphagia) strongly suggest the diagnosis.
28 Esophagitis
Factors That Exclude Diagnosis
• A normal EGD excludes esophagitis.
Ancillary Studies
Laboratory
• No laboratory studies are helpful in suggesting or conrming the diagnosis of
esophagitis. Laboratory studies may help exclude the diagnosis, e.g., positive
cardiac biomarkers in a patient with chest pain. Remember that esophagitis
may coexist with other diagnoses.
Imaging
• Plain chest x-ray usually is unremarkable.
• CT of the chest may demonstrate esophageal wall thickening, but this is often
an incidental nding during studies performed for other reasons, such as evaluation for pulmonary embolism. It also may suggest the diagnosis, but it does
not conrm the diagnosis.
423
Special Populations
Age
• Esophagitis may occur at any age. Certain diagnoses within the category may
have age predilections, such as eosinophilic esophagitis, which is more likely
in children and young adults.
• Clinical manifestations in children include:
• Emesis
• Feeding problems
• Dysphagia
• Abdominal pain
• Food impaction
• In the pediatric population, there is a denite association with other forms of
allergic disease (asthma, allergic rhinitis, urticaria, eczema)
424
C. V. Pollack, Jr. et al.
Co-morbidities
• Common co-morbidities include obesity, diabetes, immunosuppression, alcohol abuse, and cigarette smoking.
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Consideration of the diagnosis is important.
• However, it is more important to make sure the cause of chest pain is not a
more immediately life-threatening condition.
Mimics
• The entire constellation of diagnoses underlying chest pain syndrome can
mimic the pain and overall presentation of esophagitis.
• Esophagitis is more often considered a “mimic” of cardiac causes of chest pain.
Time-Dependent Interventions
• Check the ECG immediately for signs of acute myocardial ischemia.
Remember that a normal ECG does not exclude acute coronary syndrome!
• If the patient has signs of GI bleeding, initiate stabilization and resuscitation
immediately.
Overall Principles ofTreatment
• Treatment depends on identifying the underlying cause of the esophagitis.
• Inammatory causes of esophagitis often improve with acid suppression, usually from proton-pump inhibitors.
• Infectious causes need to be treated with the appropriate anti-infective agents.
• Eosinophilic esophagitis may be treated with elimination diets for removal of
putative causative agents or with topical or systemic corticosteroids.
• The use of acid suppression with proton-pump inhibitors is prescribed nearly
universally for all causes of esophagitis.