Esophageal rupture may be iatrogenic during endoscopic procedures or other instrumentation or may be spontaneous (Boerhaave syndrome). Patients are seriously ill, with symptoms of mediastinitis. Diagnosis is by esophagography with a water-soluble contrast agent. Immediate surgical repair and drainage are required.
(See also Overview of Esophageal and Swallowing Disorders.)
Endoscopic procedures are the primary cause of esophageal rupture, but spontaneous rupture may occur, typically related to vomiting, retching, or swallowing a large food bolus.
Spontaneous rupture is especially likely in patients who have untreated eosinophilic esophagitis.
The most common site of rupture is the distal esophagus on the left side. Acid and other stomach contents cause a fulminant mediastinitis and shock. Pneumomediastinum is common.
Symptoms and Signs of Esophageal Rupture
Symptoms of esophageal rupture include chest and abdominal pain, fever, vomiting, hematemesis, and shock. Subcutaneous emphysema is palpable in about 30% of patients. Mediastinal crunch (Hamman sign), a crackling sound synchronous with the heartbeat, may be present.
Diagnosis of Esophageal Rupture
Chest and abdominal x-rays
Esophagography
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Chest and abdominal x-rays showing mediastinal air, pleural effusion, or mediastinal widening suggest the diagnosis.
Diagnosis of esophageal rupture is confirmed by esophagography with a water-soluble contrast agent, which avoids potential mediastinal irritation from barium. CT of the thorax detects mediastinal air and fluid but does not localize the perforation well. Endoscopy may miss a small perforation.
Treatment of Esophageal Rupture
Endoscopic stenting or surgical repair
Pending surgical repair or endoscopic stenting, patients should receive broad-spectrum antibiotics (eg, gentamicin plus metronidazole or piperacillin/tazobactam) and fluid resuscitation as needed for shock. Even with treatment, mortality is high.
