Perforation of the esophagus

Alternative names
Esophageal perforation

Definition

An esophageal perforation is a hole in the esophagus, the tube through which food passes from the mouth to the stomach.

Causes, incidence, and risk factors

A perforation is a hole through which the contents of the esophagus can pass into the mediastinum, the surrounding area in the chest. This often results in infection of the mediastinum (mediastinitis).

The most common cause of an esophageal perforation is injury during a medical procedure such as esophagoscopy (a procedure to examine the esophagus) or placement of a naso-gastric tube.

The esophagus may also become perforated as the result of a tumor, gastric reflux with ulceration, other disease process, a mechanical problem such as violent retching, or swallowing a foreign object or caustic chemicals.

Less common causes include injuries from penetrating or blunt trauma, and injury to the esophagus during an operation on another organ near the esophagus. Rare cases have also been associated with childbirth, defecation, seizures, heavy lifting, and forceful swallowing.

Symptoms

The main symptom is pain at first, but the condition can progress to shock - even death - if untreated.

Patients with a perforation in the uppermost portion of the esophagus may have neck pain or stiffness and air bubbles underneath the skin.

Patients with a perforation in the middle portion or lowermost portion of the esophagus may have difficulty swallowing, chest pain, and difficulty breathing.

Signs and tests

Signs include fast breathing, rapid heart rate, low blood pressure and fever. A chest x-ray may reveal that there is air in the soft tissues of the chest, fluid that has leaked from the esophagus into the space around the lungs, or collapse of the lung.

A chest CT scan may reveal the formation of an abscess in the chest or evidence of esophageal cancer. A water-soluble contrast swallow (motion picture x-rays after drinking dye) may show the location of the perforation.

Treatment

The treatment can be divided into initial and definitive phases. Early surgery is appropriate for almost all patients. Every effort should be made to have surgery within 24 hours of when the perforation occurred.

The initial phase includes diagnostic studies to determine the location and cause of the hole, administer IV fluids, and administer IV antibiotics to prevent or treat infection. Fluid that has collected around the lungs may be treated with a chest tube to drain it away.

The definitive treatment is to repair the perforation. For some patients with perforation in the uppermost (neck region) of the esophagus, the perforation may heal by itself if the patient does not eat or drink for a period of time. In this case, nutrition must be provided by another source, such as a stomach feeding tube.

For perforation in the mid-portion and lower-most portions of the esophagus, an operation is usually required for repair. Depending on the size and location of the perforation, the leak may be treated by simple repair or by removal of the esophagus.

Expectations (prognosis)
For patients with an early diagnosis (less than 24 hours), the outlook is good. The survival rate is 90% when surgery is accomplished within 24 hours. However, this rate drops to about 50% when treatment is delayed.

Complications

Possible complications include:

     
  • Permanent damage to the esophagus (narrowing or stricture)  
  • Abscess formation in and around the esophagus  
  • Infection in and around the lungs.

Calling your health care provider

Demand immediate medical attention if you are in the hospital. If not, go to the emergency room or call 911 if you have recently had surgery or the placement of a tube in the esophagus and have pain, difficulty swallowing or breathing, or have other reason to suspect you may have esophageal perforation. Time is of the essence in treating this condition.

Prevention

Because of their nature, these injuries are difficult to prevent.

Johns Hopkins patient information

Last revised: December 4, 2012
by Janet G. Derge, M.D.

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