Perforation of the esophagus is usually iatrogenic
(instrumental perforations at therapeutic endoscopy) it can be
managed conservatively ( not all the time ). Barotrauma
(spontaneous perforation). is often a life-threatening condition
that regularly requires surgical intervention. M.A.Kubtan3
Slide 5
Potentially lethal complication due to mediastinitis and septic
shock. Numerous causes, but may be iatrogenic. Surgical emphysema
is virtuall pathognomonic. Treatment is urgent; it may be
conservative or surgical, but requires specialised care.
M.A.Kubtan4
Slide 6
Boerhaave syndrome : This occurs classically when a person
vomits against a closed glottis. The pressure in the esophagus
increases rapidly, and the esophagus bursts at its weakest point in
the lower third sending a stream of material into the mediastinum
and often the pleural cavity. Boerhaave syndrome is the most
serious type of perforation. This causes rapid chemical irritation
in the mediastinum and pleura followed by infection if untreated.
M.A.Kubtan5
Slide 7
6 Barotrauma has also been described in relation to other
pressure events when the patient strains against a closed glottis
(e.g.defaecation, labour, weight-lifting).
Slide 8
The clinical history is usually of severe pain in the chest or
upper abdomen following a meal or a bout of drinking. Associated
shortness of breath is common. There may be a surprising amount of
rigidity on examination of the upper abdomen, even in the absence
of any peritoneal contamination. The diagnosis can usually be
suspected from the history and associated clinical features.
M.A.Kubtan7
Slide 9
A chest X-ray is often confirmatory with air in the
mediastinum, pleura or peritoneum. Pleural effusion occurs rapidly.
A contrast swallow or CT is nearly always required to guide
management M.A.Kubtan8
Slide 10
9 severe subcutaneous emphysema 33 years old woman secondary to
prolonged labor during normal vaginal delivery
Slide 11
M.A.Kubtan10
Slide 12
M.A.Kubtan11 A contrast swallow
Slide 13
M.A.Kubtan12
Slide 14
Aero digestive fistula is most common and usually encountered
in primary malignant disease of the esophagus or bronchus. Erosion
into an adjacent structure with fistula formation is more common.
Free perforation of ulcers or tumors of the esophagus into the
pleural space is rare. Coughing on eating and signs of aspiration
pneumonitis may allow the problem to be recognized.
M.A.Kubtan13
Slide 15
Covering the communication with a self-expanding metal stent is
the usual solution. Erosion into a major vascular structure is
invariably fatal. M.A.Kubtan14
Slide 16
Foreign bodies : The esophagus may be perforated during removal
of a foreign body. Occasionally, an object that has been left in
the esophagus for several days will erode through the wall.
Instrumental perforation : Instrumentation is by far the most
common cause of perforation. Perforation can occur in the pharynx
or esophagus, usually at sites of pathology or when the endoscope
is passed blindly. Perforation may follow biopsy of a malignant
tumor. M.A.Kubtan15
Slide 17
The esophagus may be perforated by guide wires, graduated
dilators or balloons, or during the placement of self-expanding
stents. The risk is considerably higher in patients with
malignancy. M.A.Kubtan16
Slide 18
Forceful vomiting may produce a mucosal tear at the cardia
rather than a full perforation. In MalloryWeiss syndrome, vigorous
vomiting produces a vertical split in the gastric mucosa. Tear
immediately below the squamocolumnar junction at the cardia in 90%
of cases. In only 10% is the tear in the esophagus.
M.A.Kubtan17
Slide 19
M.A.Kubtan18
Slide 20
Perforation of the esophagus usually leads to mediastinitis.
The aim of treatment is to limit mediastinal contamination and
prevent or deal with infection. The event causing the perforation
(spontaneous vs. instrumental). Underlying pathology (benign or
malignant). The status of the esophagus before the perforation
(fasted and empty vs. obstructed with a stagnant residue).
M.A.Kubtan19
Slide 21
attempted suicide. Accidental ingestion occurs in children and
when corrosives are stored in bottles labeled as beverages. All can
cause severe damage to the mouth, pharynx, larynx, esophagus and
stomach. In general, alkalis are relatively odorless and tasteless,
making them more likely to be ingested in large volume.
M.A.Kubtan20
Slide 22
Significant stricture formation occurs in about 50% of patients
with extensive mucosal damage. M.A.Kubtan21
Slide 23
M.A.Kubtan22 Multiple stricture of the body of esophagus
Slide 24
Most congenital malformations develop during embryonic life
between the third and eighth weeks of gestation. M.A.Kubtan23
Slide 25
A blind proximal pouch with a distal tracheo- esophageal
fistula is the most common type. Affected infants typically present
Soon after birth with frothy saliva. cyanotic episodes, exacerbated
by any attempt to feed. The preceding pregnancy may have been
complicated by maternal polyhydramnios. M.A.Kubtan24
Slide 26
M.A.Kubtan25
Slide 27
Is confirmed by failure to pass a 10 Fr oro-gastric tube into
the stomach. The tube is visible within an upper esophageal pouch
on the chest radiograph. The presence of abdominal gas signifies
the tracheo- esophageal fistula. Associated anomalies are common
and include cardiac, renal and skeletal defects. M.A.Kubtan26
Slide 28
Surgical repair : The esophageal ends are anastomosed. Division
and repair of tracheo esophageal tract. M.A.Kubtan27
Slide 29
Infants with pure esophageal atresia and no tracheo- esophageal
fistula. Usually best managed by a temporary gastrostomy. Delayed
primary repair. Except for very-low-birth weight babies and those
with major congenital heart disease, most infants with repaired
esophageal atresia have a good prognosis. M.A.Kubtan28