Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

Abstract

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

Figure 1

Plain chest radiography with a water soluble contrast swallow, showing contrast leakage in a patient with spontaneous rupture of the esophagus.

Figure 2

Computer tomography (CT) with an oral contrast swallow, showing distal contrast leakage and gas bubbles in the mediastinum only few hours after pneumatic dilatation for achalasia.

Figure 3

Endoscopic view of a distal spontaneous perforation 24 hours after onset of clinical symptoms, according to the patient. Endoscopic appearance, however, may suggest a time period exceeding at least 36-48 hours from onset of symptoms to endoscopic diagnosis.

Figure 4

Management suggestions for iatrogenic esophagus perforation [adopted from 41].

Figure 5

Management suggestions for spontaneous esophagus perforation [adopted from 41].