AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Background

An esophageal tear is defined as a breach of esophageal wall, whether due to a mucosal tear, perforation or rupture. Esophageal tears are life-threatening conditions that require prompt diagnosis and emergency treatment. Currently, the most common causes of esophageal tear, perforation, or hematoma are iatrogenic factors.

An esophageal tear allows upper GI contents to egress from the esophageal lumen into the soft tissues of the neck, the mediastinum and pleural space, the peritoneal cavity, and possibly multiple sites, depending on the location of the injury. Cervical soft tissue infections, mediastinitis, pleuritis, or peritonitis ensue, followed by systemic sepsis and death if the condition remains untreated. Esophageal perforations or tears almost always require surgical correction, though a small and contained esophageal tear is occasionally managed expectantly.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center.

Pathophysiology

Esophageal perforations, Mallory-Weiss tears, and esophageal hematomas may involve traumatic injury to the esophagus following instrumentation, such as after gastric lavage or upper GI endoscopy. Lately, increased use of diagnostic and therapeutic endoscopy, as well as esophageal surgery, has made endoscopic instrumentation the most common cause of esophageal perforation.

In more than 90% of cases, perforation occurs in the lower third of the esophagus. A tear 0.6-8.9 cm long has a predilection for the left posterolateral region (90%). This predilection for left-sided perforations may be caused by lack of adjacent supporting structures, thinning of musculature in lower esophagus, and anterior angulation of esophagus at left diaphragmatic crus. Tears usually extend superiorly. Perforation of esophagus resulting from instrumentation or trauma does not appear to have a specific site predilection.

Types of esophageal injuries

Esophageal injuries can be classified into ruptures and mucosal tears.

Esophageal rupture occurs because the esophagus, unlike the rest of the alimentary tract, lacks a serosal layer, which usually contains collagen and elastic fibers. The esophageal wall is thus comparatively weaker and may rupture at a lower intraluminal pressure. Vomiting is usually the precipitating factor for spontaneous esophageal rupture. Esophageal rupture is a life-threatening injury. Prompt diagnosis and treatment provide the best likelihood for survival; however, delayed diagnosis is common, resulting in significant morbidity and mortality.

Esophageal tears are estimated to occur in 1% of patients with blunt trauma, but they are far more common with penetrating or iatrogenic trauma. Esophageal rupture carries a high mortality rate secondary to rapidly developing mediastinitis. Survival improves dramatically if the esophageal injury is recognized and treated within 24 hours of its occurrence.

About 82% of esophageal tears due to blunt trauma occur in the cervical and upper thoracic esophagus. It is postulated that compression of the esophagus between the sternum and vertebral column is the mechanism of injury. Tears may also occur in the distal esophagus just above the gastroesophageal junction along the left posterolateral wall. The mechanism of injury in this setting is probably similar to spontaneous rupture in Boerhaave syndrome when esophageal pressures rise against a closed glottis.

Boerhaave syndrome

Boerhaave description of a case of esophageal rupture associated with forceful retching and vomiting was published in 1724. This clinical syndrome bears his name today.

One of the most famous anecdotes in the annals of medical history concerns an esophageal rupture. The story is about a Dutch doctor named Hermann Boerhaave and a gluttonous patient, the Grand Admiral of the Dutch Fleet, the Baron van Wassenaer. The admiral was a habitual user of emetics, which he self-administered to purge himself after large meals. In what was to be a fatal move, when van Wassenaer induced vomiting after dining on goose. He was suddenly stricken with severe, intense pain localized to the upper abdomen. Crying out in agony, he expressed certainty of his own impending death. In less than 24 hours, he was dead. Boerhaave performed an autopsy and discovered a tear of the lower esophagus associated with spillage of gastric contents into both pleural spaces. On opening the thorax, Boerhaave was struck by the aroma of goose flesh. The admiral had a transverse tear, a rare condition.

Mallory-Weiss tear

In 1929, Kenneth Mallory and Soma Weiss first described a syndrome characterized by esophageal bleeding caused by a mucosal tear in the esophagus as a result of forceful vomiting or retching. The initial description was associated with alcoholic bingeing; however, with the advent of endoscopy, Mallory-Weiss tears have been diagnosed in many patients with no history of alcohol intake.

Any disorder that initiates vomiting may also result in the development of a Mallory-Weiss tear, which occurs as a linear laceration at the gastroesophageal junction because the esophagus and stomach are cylindrical at this point. The cylindrical shape makes longitudinal tears occur more easily than circumferential tears.

Two mechanisms are postulated play a part in the development of Mallory-Weiss tears: (1) a rapid increase in intragastric pressure, which increases the forceful fluid ejection through the esophagus, and (2) a significant change in transgastric pressure (ie, difference in pressure across the gastric wall) because negative intrathoracic pressure and positive intragastric pressure leads to distortion of the gastric cardia, resulting in a gastric or esophageal tear. Because of these factors, Mallory-Weiss tears occur more commonly in patients with hiatus hernias.

Although the tear typically occurs after repeated episodes of vomiting or retching, it may occur after a single incident. Most of the written reports of these tears relate to adults; however, Mallory-Weiss tears also occur in children.

Han and Tishler described 5 patients with perforation of the abdominal segment of the esophagus. In 2 patients with a tear of the abdominal segment alone, perforation occurred into the retroperitoneal space. In the other 3, the tear extended above the diaphragm. Perforation involved both the thorax and lesser sac in one and into both the thorax and retroperitoneal space in the other 2. The clinical manifestations and treatment of these patients differ from those of the more common intrathoracic perforation.

Frequency

United States

Esophageal tears are estimated to occur in 1% of patients with blunt trauma, but they are far more common with penetrating or iatrogenic trauma. Esophageal rupture carries a high mortality rate secondary to rapidly developing mediastinitis. Survival improves dramatically if the esophageal injury is recognized and treated within 24 hours of its occurrence. Boerhaave syndrome is rare, with an estimated incidence of only 1 case in more than 6000 patients. It accounts for 15% of cases of esophageal rupture or perforation.

International

There is no data to suggest that frequency of esophageal tears is different from that in the United States.

Mortality/Morbidity

Even with prompt therapy, the mortality rate is high, varying from 30-50%. With delay in diagnosis, the mortality rate exceeds 90%. Mortality rates from perforation caused by instrumentation are lower than other causes (15-20%), although clearly still notable.

Vertebral osteomyelitis has been reported in association with penetrating and after blunt traumatic esophageal rupture.

• The major complication of a Mallory-Weiss tear is bleeding. Patients present with variable bleeding, which can range from a few specks or streaks of blood mixed with mucus to copious amounts of fresh red blood. In adults, shock occurs in up to 20% of patients bleeding from Mallory-Weiss tears who present to emergency departments, while up to 45% of patients develop postural hypotension. In contrast, children rarely have hemodynamic instability.
• Iatrogenic perforation and spontaneous rupture had the same poor prognosis. Nonsurgical treatment is rarely indicated. Esophagectomy is a good option in the case of a nonsuturable esophagus or delayed surgery.
• Graeber et al conducted a review to ascertain whether patients with Boerhaave syndrome have morbidity and mortality rates higher than those of patients with endoscopic iatrogenic esophageal perforations. They reviewed the records of 3 medical centers from 1960 to 1985 and identified 11 patients with Boerhaave syndrome (group B) and 19 with iatrogenic perforations (group E).In group B, 4 cases were diagnosed >24 h after perforation. Nine patients were treated surgically; of these, 1 died. Two group B patients who were treated conservatively survived. In group E, 4 cases were diagnosed >24 h after perforation. Of 19 patients, 15 were treated surgically, and 4, medically. In group E, 3 patients died (1 surgically treated, 2 conservatively treated). These results suggest little difference in mortality rates between the 2 groups of patients as long as the diagnosis is made early and therapy instituted promptly.

Race

No information about racial predilection is available.

Sex

• Boerhaave disease is generally associated with vomiting and customarily occurs after drinking and eating binges. It is more commonly observed in men than in women.
• Mallory-Weiss tears occur with equal frequency in both sexes in adults, but they have different causes. In women of childbearing age, the most common cause of these tears is hyperemesis gravidarum (severe persistent nausea and vomiting), which usually occurs in the first trimester. Any female adolescent presenting with a Mallory-Weiss tear should be evaluated for pregnancy.

Age

• Spontaneous esophageal perforation usually is observed in patients aged 40-60 years. Iatrogenic perforation is generally associated with preexisting pathology; therefore, it is a disease of the fifth and later decades.
• Boerhaave syndrome is rare in younger patients. Isolated case reports have documented its occurrence in children.
• Mallory-Weiss tears usually occur in the fifth or sixth decades of life. In children, tears are more commonly observed in older children and adolescents secondary to increased intragastric and transgastric pressures that develop at an older age.

Anatomy

The esophagus extends from cricopharyngeal muscle in pharynx (15-18 cm from incisor teeth) to the gastroesophageal junction (T11/T12) and is 25 cm long.

Anatomically, the esophagus can be subdivided 4 parts: (1) The cervical esophagus extends from the lower border of cricoid cartilage to suprasternal notch. (2) The upper thoracic esophagus extends from the suprasternal notch to the tracheal bifurcation. (3) The midthoracic esophagus extends from the tracheal bifurcation to just above gastroesophageal junction. (4) The lower thoracic and abdominal esophagus usually represents the gastroesophageal junction. This subdivision is important clinically and both from endoscopy and imaging point of view.

Normally 2 areas of high pressure are present at rest: the upper esophageal sphincter at the cricopharyngeus muscle and the lower esophageal sphincter at 2-4 cm proximal to esophagogastric junction at level of diaphragm. The tone of the lower esophageal sphincter is affected by gastrin, acetylcholine, and serotonin but not vagotomy.

The arterial blood supply of cervical esophagus is derived from the inferior thyroid artery, whereas the upper thoracic-bronchial and intercostal arteries, lower thoracic-aortic branches, abdominal-left gastric and inferior phrenic arteries supply the rest of the esophagus. The draining veins form an extensive submucosal plexus that communicates with periesophageal veins, flows into inferior thyroid, azygous and gastric veins. The lower esophagus is an important site of portosystemic anastomoses, which explains this being the commonest site for esophageal varices in portal hypertension

Lymphatic drainage from the esophagus is provided by freely anastomosing networks of lymph vessels, which facilitate length-wise tumor dissemination. The upper third drains into cervical nodes; the middle third, to paraesophageal and paratracheal mediastinal nodes; and the lower third, to nodes around aorta and celiac axis

Images show normal points of narrowing at the level of the cricoid cartilage, aortic arch, anterior crossing of left main bronchus and left atrium, diaphragm. On conventional chest radiographs, the right wall of the normal upper intrathoracic esophagus often can be seen as a shallow S-shaped line extending from the lung apex to the azygos arch. Air is often present within the esophagus, but when air is absent, the right wall of the esophagus is seen as a pleuroesophageal line or stripe. Inferior to the azygos arch the right wall of the esophagus is in contact with the lower lobe of the right lung and the azygos vein as it ascends toward the arch. This part of the lung has been called the azygoesophageal line.

The configuration of the azygos arch has considerable anatomic variation, which is reflected in the shape of the superior part of the azygoesophageal line. The configuration of the upper few centimeters of the azygoesophageal line is always straight or concave towards the lung. In rare cases, this line is convex shaped suggesting a subcarinal mass. The line is usually of different configuration and convex in children particularly children younger than 3-years old. In healthy people, the azygoesophageal line can usually be traced inferiorly to the posterior costophrenic angle.

On occasion, the left lung may make contact with the esophageal wall, outlining the esophagus from both the right and the left. The presence of air in the lumen of the esophagus may allow for measurement of the esophageal wall thickness and comparison of wall thickness on the right and left sides. The most common site where is air is trapped in esophageal lumen is just inferior to the aortic arch impression.

The normal esophagus is visible on all CT and MRI sections from the neck down to esophageal hiatus. In the presence of sufficient mediastinal fat, the whole circumference of the esophagus is well visualized, and the presence of air in the lumen depicts the uniform thickness of the esophageal wall. When no air is present in the esophagus, it appears as an oval-to-round mass in the posterior mediastinum. The esophagus has signal intensity similar to that of muscle on T1-weighted MRI but is hyperintense relative to muscle on T2-weighted images.

Clinical Details

Clinical presentation

The clinical presentation of esophageal tears/rupture includes hematemesis, chest pain, dysphagia, odynophagia and rapid onset of sepsis, fever, tachycardia, hypotension and shock. Patients often complain of sudden, sharp epigastric pain radiating to the interscapular area. Dyspnea, cyanosis, and shock are late symptoms.

Causes

Iatrogenic perforations account for approximately 55% of esophageal perforations. In a large case series of patients undergoing esophagoscopy, the incidence of perforations was 1.7% (17 cases in 1011 procedures). Of these 17 cases, tumors were found in 8 and achalasia was found in 4; the remaining 5 had strictures or an esophageal anastomosis. The generally accepted complication rates are from 2-6% after pneumatic dilatation for achalasia.

Foreign bodies or traumatic perforations cause all other cases of esophageal perforation. Esophageal rupture secondary to blunt external trauma is very rare, with few cases reported in world literature. Closed chest trauma account for 10% of esophageal perforations, and retained foreign bodies account for 14% of esophageal perforations.

Mallory-Weiss tears are the cause for approximately 10-15% of all episodes of hematemesis in adults; however, these tears occur much less commonly in children ( <5% of all upper GI bleeding episodes).

Esophageal rupture during balloon dilation for esophageal stricture

Kang et al reviewed the prevalence and clinical importance of esophageal rupture during balloon dilation for treatment of esophageal stricture. They reviewed the case records of 96 consecutive patients of fluoroscopically guided esophageal balloon dilation were for esophageal strictures.

Esophageal rupture was classified into three types: Type 1 was intramural; type 2, transmural; and type 3, transmural with mediastinal leakage. Each patient underwent 1-7 procedures, for a total of 191. Esophageal rupture occurred in 20 (21%). Type 1 rupture occurred in 8 patients, type 2 in 11, and type 3 in 1. All esophageal ruptures were detected immediately after the procedure.

Sixteen patients were treated with fasting, parenteral alimentation, and antibiotics; two were treated surgically; and two were treated with stent placement. No treatment-related deaths occurred. A substantial number of patients who developed type 1 rupture had associated clinical symptoms, such as pain and fever, but responded to conservative management and were therefore included as having complications of esophageal balloon dilation.

Preferred Examination

Spontaneous rupture of the esophagus continues to be diagnosed late despite a classical history and/or abnormal chest radiograph. Endoscopic assessment of perforations is safe; in combination with a contrast-swallow study, the results can confidently predict the success of nonoperative management in patients with contained or controlled rupture.

Conventional radiographs are generally used in the initial assessment of patients with suspected esophageal perforation, followed by oral contrast-enhanced examination, which can be critical in determining the presence and precise location of esophageal perforation.

Endoscopy is safe and is extremely useful particularly if an esophageal tear is suspected. Most signs seen on conventional radiographs are better depicted on CT.

The use of MRI and US is anecdotal and at the present time; these studies have little if any role in the diagnosis of esophageal perforation.

Superselective left gastric angiography can be performed as a prelude to transcatheter embolization of Mallory-Weiss tears.

Limitations of Techniques

Conventional radiographs may be normal in up to 10% patients with esophageal perforations. Endoscopy, oral contrast-enhanced studies and angiography are invasive procedures.

Many causes can result in mediastinal fluid, esophageal thickening, and mediastinitis, and extraluminal air within the mediastinum, all of which provide a potential for misdiagnosis. The angiographic diagnosis of upper GI bleeding has several pitfalls.

DIFFERENTIALS

Section 3 of 12  

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• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Other Problems to be Considered

Pulmonary embolism
Spontaneous splenic rupture
Esophageal, gastric, and duodenal perforations

RADIOGRAPH

Section 4 of 12  

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Findings

Upper and mid esophageal perforations

The most frequent site of these perforations at the level of the cricopharyngeus muscle and most perforations are iatrogenic. The conventional radiographic findings include widening of the precervical soft tissues, air in the precervical soft tissues, widening of the superior mediastinum, and a right-sided hydrothorax.

Lower esophageal perforations

Boerhaave ruptures usually occur in the left inferior posterolateral wall of the esophagus. The tear is not directly identified on chest radiographs and one must rely on indirect signs along with a high index of suspicion. These indirect signs include pneumomediastinum and left-sided pneumothorax. With Boerhaave ruptures, pleural effusions are striking, particularly on the left, where it is often associated with left lower lobe consolidation.

Other findings include hydropneumothorax, hydrothorax (usually unilateral), pneumomediastinal air along the inferior descending aorta, air in the left cardiovertebral angle of the diaphragm (V sign of Naclerio), subcutaneous emphysema in the neck, and delayed mediastinal widening due to mediastinitis.

Other findings

Widening of the mediastinum is usually the result of inflammation or abscess formation. The extent of the widening and the configuration of the widening depend upon its cause. An important sign of mediastinitis secondary to esophageal perforation is the presence of air in the mediastinum. This air may be bubbly or streaky. Air may extend into the neck or the retroperitoneum. These findings are better depicted on CT than on radiography.

If this injury is suspected, an esophagogram obtained with nonionic contrast material is recommended. The morbidity and mortality from delayed treatment of this injury are high. About 90% esophagograms are positive in showing a leakage of contrast agent.

Technique

Cassel et al described a simple method for obtaining double-enhanced images of the lower esophagus with the patient in a prone position. This technique has a high success rate, allows repeated imaging, and is easily incorporated into routine upper GI studies. Diagnostic double-enhanced studies were obtained in 78% of 28 patients. Ten abnormalities, including a Mallory-Weiss tear, were demonstrated. Single-contrast esophagograms, obtained immediately afterward, demonstrated only 6 abnormalities.

Degree of Confidence

Plain radiographs are noninvasive and can be obtained in most emergency situations. The images show positive signs in 80-90% of cases of esophageal tears.

False Positives/Negatives

Esophageal tears are not directly identified on conventional radiographs, and one must rely on indirect signs along with a high index of suspicion. Conventional radiographs are normal in 9-12% of confirmed esophageal perforations. Mallory-Weiss tears are not seen on conventional radiographs and may not be visualized on contrast radiography of the esophagus. Pneumothorax, mediastinal emphysema, mediastinitis, and hydrothorax have many causes with a potential for false-positive and false-negative diagnosis.

CT SCAN

Section 5 of 12  

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• Ultrasound
• Nuclear Medicine
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• References

Findings

CT abnormalities include extraluminal air, periesophageal fluid, esophageal thickening, and extraluminal contrast. These CT findings may be the first clue to the correct diagnosis of esophageal perforation.

CT findings of esophageal rupture include focal extraluminal air collections at the site of tear and a hematoma of the mediastinal or esophageal wall. Occasionally, a tract at the site of the tear can be identified on CT scans. In the setting of severe blunt chest trauma, the esophagus can also be obstructed and entrapped by fracture-dislocations of the thoracic spine, as demonstrated on chest or thoracic spinal CT. The diagnosis of esophageal rupture is usually confirmed with a swallow study with nonionic oral contrast material.

CT findings in esophageal tear/perforation can be summarized as follows: Extraluminal air in the mediastinum/surrounding the esophagus is the most reliable sign and when taken in conjunction with the clinical presentation has 92% accuracy. Gas may appear as is discrete collections, single or multiple, particularly with mediastinal abscess formation. Air fluid levels may also be seen within mediastinal abscesses.

Other findings include obliteration of fat planes in the mediastinum due to inflammation, periesophageal/mediastinal fluid (92% accuracy), esophageal thickening, pleural effusions (usually unilateral), extravasation of oral contrast material in the periesophageal tissues, and a tract at the site of the tear (in rare cases).

Degree of Confidence

Esophageal perforation can be a catastrophic event for a patient regardless of the etiology of the perforation. Contrast-enhanced esophagograms can typically diagnose an esophageal perforation if the clinical symptoms or history suggest the diagnosis. Often, however, the clinical features are atypical and a CT scan is performed early in the patient's workup. CT has dramatically changed the imaging approach to the mediastinum, which can depict precise cross-sectional mediastinal anatomic detail defining fat, water, and near muscle density tissues.

False Positives/Negatives

Many causes of extraluminal air within the mediastinum, mediastinal fluid, and esophageal thickening are reported; these provide a potential for false-positive and false-negative diagnoses. CT findings should always be interpreted in the light of the patient's clinical presentation.

MRI

Section 6 of 12  

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• Mri
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Findings

MRI can depict the normal esophageal and mediastinal anatomy and has been used in the diagnosis of esophageal masses, varices, and esophagitis. However, the role in MRI in an emergency setting, particularly in the diagnosis of esophageal rupture, has not been defined.

Mediastinitis often accompanies esophageal perforation, where an expected fluid low signal intensity may be depicted on T1-weighted MRI with high signal intensity on T2-weighted and proton density–weighted images.

False Positives/Negatives

Many causes of mediastinitis provide the potential for false diagnoses.

ULTRASOUND

Section 7 of 12  

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Findings

Ultrasonography has not been used in the diagnosis of esophageal tears and perforations; however, transesophageal endosonography has been used to evaluate posterior mediastinitis, which is known complication of esophageal tears.

In 2003, Fritscher-Raven et al prospectively evaluated the value of transesophageal endosonography with guided fine-needle aspiration in the diagnosis and identification of etiologic agents in critically ill patients with suspected posterior mediastinitis. Transesophageal endosonography detected mediastinal lesions in 16 (89%) of 18 patients and was more accurately diagnostic than CT (P = .0082).

Fifteen patients had undergone surgery (11 esophagectomy, 1 other esophageal surgery, 1 head/neck cancer surgery, 1 complication after dilatational tracheostomy, and 1 intervention after polytrauma). Three patients were thought to have nonpostoperative mediastinitis. In 16 patients, infectious organisms were detected (14 bacterial, 1 fungal, 1 tuberculosis).

Culture and sensitivity of transesophageal endosonography/fine-needle aspiration specimens led to appropriate drug therapy. In 2 patients, methicillin-resistant Staphylococcus aureus was detected, leading to isolation care. Twelve patients improved; 6 died. Of the 2 patients in whom transesophageal endosonography did not detect a mediastinitis, 1 had a false-negative finding on autopsy. There were no complications.

The authors concluded that bedside transesophageal endosonography/fine-needle aspiration of posterior mediastinal lesions in critically ill patients is an effective and relatively noninvasive way to detect mediastinitis and provide material to identify the etiologic agent. It is particularly useful in patients after esophagectomy.

Degree of Confidence

At present, sonography has no role in the diagnosis of esophageal tears.

NUCLEAR MEDICINE

Section 8 of 12  

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Findings

Radionuclide studies have been successfully used to determine the site of GI bleeding; however, their use in evaluating esophageal bleeding from Mallory-Weiss syndrome has not been described.

ANGIOGRAPHY

Section 9 of 12  

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Findings

Active bleeding from Mallory-Weiss tears can be demonstrated on superselective angiography of the left gastric artery. Extravasated contrast medium from the tear may either flow cephalad in the esophagus outlining the esophageal lumen or enter the stomach. Occasionally a linear collection of contrast may be seen in a posterior Mallory-Weiss laceration. Bleeding can be controlled by vasopressin infusion or particulate embolization.

Degree of Confidence

In most patients with upper GI hemorrhage from Mallory-Weiss tear, the bleeding ceases spontaneously, and specific therapy is not required. Patients who continue to bleed and those who rebleed present specific therapeutic problems. In this instance, superselective angiography may provide therapeutic options. GI bleed is demonstrated only when the patient is actively bleeding at the time of angiography, although with meticulous technique, inflammation (which often accompanies Mallory-Weiss tears) may be depicted.

False Positives/Negatives

It is difficult to differentiate bleeding Mallory-Weiss laceration from a high gastric erosions or ulcers on angiography alone. A false-positive diagnosis may occur in some patients in whom superselective left gastric angiography demonstrates a marked increase in size and number of vessels supplying the gastric fundus associated with an increased capillary blush. This appearance can be normal; however, gastritis, which often accompanies Mallory Weiss tears, can have a similar appearance.

INTERVENTION

Section 10 of 12  

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Esophageal perforations that are treated surgically within 24 hours have good results. The outcome obviously depends on comorbidity and to whether postoperative pulmonary complications occur. Enteral nutrition should be avoided in cases of primary esophageal resection to facilitate the surgical reconstruction at the second operation. In a patient with a spontaneous rupture of esophagus, the anesthetic considerations include avoidance of further aggravation of the esophageal tear, and resuscitation from a morbid inflammatory condition.

Carsen et al described their experience of transcatheter embolization in 5 patients with Mallory-Weiss tears in whom massive uncontrolled upper GI bleeding was treated by Gelfoam embolization of the left gastric artery. Four required no further therapy. In 1 case, permanent hemostasis was not achieved because of extension of the tear to branches of the inferior phrenic artery. Because Mallory-Weiss tears are usually self-healing, embolization is potentially the primary treatment modality. Surgery can be reserved for treatment of transmural perforation or recurrent bleeding.

Clark describes 5 patients with refractory GI bleeding from Mallory-Weiss tears of the esophagus, which were successfully treated with intra-arterial infusions of vasopressin. Although transcatheter embolization can to control the hemorrhage from these lesions, the author concluded that increased experience with and ease of vasopressin infusion supports the use of infusion therapy as primary treatment when more conservative measures are inadequate. Embolization techniques may be reserved for cases in which vasopressin therapy is contraindicated or unsuccessful.

Fisher et al successfully treated 15 patients with Mallory Weiss tears by using angiotherapy involving either intra-arterial vasopressin infusion (13 cases) or arterial embolization (2 cases). Permanent hemostasis was achieved in most patients treated.

Adamek et al assessed the frequency of esophageal perforation after endoscopic procedures in a highly specialized endoscopy unit and compared clinical outcomes in patients undergoing surgical or conservative management. Seventeen esophageal perforations (1.7%) occurred in 1011 procedures. Four resulted from balloon dilatation, and 13 were secondary to bougienage. Six patients were treated surgically (35%); all recovered uneventfully. Eleven patients were treated conservatively, mainly because they were not candidates for surgery. The survival rate in this group was 82%; only 2 patients died (both had underlying malignant disease). The authors concluded that, in well-selected cases, nonoperative treatment can be considered with favorable results.

In the neonatal period, perforation of the esophagus or pharynx may occur during placement of endotracheal or nasogastric tubes. Controversy exists whether medical or surgical therapy is better in the management of these perforations.

Johnson et al describe 9 neonates with esophageal or pharyngeal perforation who were treated medically with antibiotics, nutritional support, and closed chest-tube drainage of pneumothoraces. All perforations healed without surgical repair. No mortality or morbidity occurred secondary to these perforations. This study, together with a review of the 73 patients in the literature, indicates that perforations of the pharynx and esophagus can be satisfactorily managed with medical means. Routine early surgical exploration has not apparent advantage.

Only complications, such as mediastinitis and mediastinal mass formation, seem to require surgical treatment. Medical therapy with close observation for signs of sepsis and/or mediastinal changes enable most neonates to avoid surgery and identifies those for whom surgery is definitely indicated.

Medical/Legal Pitfalls

• The classic triad of pain, fever, and subcutaneous or mediastinal emphysema is associated with esophageal perforation. All 3 of these components might not be present in each patient.
• Spontaneous rupture of the esophagus continues to be diagnosed late despite a classical history and/or abnormal chest radiograph. Endoscopic assessment of perforations is safe and in combination with a contrast swallow can confidently predict patients with contained or controlled rupture in whom nonoperative management is successful.
• Rupture of the esophagus, trachea and or bronchi may be seen with severe injuries of the thorax but may be obscured by other more dramatic injuries. Injuries of this type usually give changes on the chest radiograph in the coarse of the first 24 hours.
• In young children the possibility of pharyngeal or esophageal perforation as a part of child abuse must be considered (Abli, 1990).
• A potential problem with left gastric artery embolization in Mallory-Weiss tears is gastric infarction, though it is unlikely that infarction will occur in an intact stomach because the stomach has a rich blood supply.
• Most patients complain of abdominal pain with the commencement of vasopressin infusion into the GI arteries. The pain generally lasts 10-15 minutes.
• • Some patients evacuate during the procedure. If the catheter tip dislodges and enters a small vessel during the procedure, bowel ischemia may result.
  • During vasopressin infusion, the catheter tip must be checked constantly by performing angiography.
  • The dose used in intra-arterial infusion is small, but urine output should be constantly checked. Water retention and electrolyte balance may need treatment with diuretics and suitable electrolyte infusion.
  • Cardiotoxicity is generally not a problem with the small doses used, but vasopressin infusion should be used with care in patients with compromised cardiac output. Peripheral vasoconstriction with vasopressin has also been described; this can cause a mottled appearance of the limbs. On occasion, the vasoconstriction may be disabling enough to warrant cessation of the infusion.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Media file 1:  This 36-year-old man presented with hematemesis after an alcoholic binge. Endoscopy shows oozing blood from a base of a clot overlying a Mallory-Weiss tear (arrow).
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Media type:  Photo

Media file 2:  Posteroanterior chest radiograph shows a right-sided hydropneumothorax after an esophageal rupture.
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Media type:  X-RAY

Media file 3:  Contrast-swallow study in the same patient as in Image 2 shows leakage of contrast agent at the level of the carina.
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Media type:  X-RAY

Media file 4:  Water-soluble contrast study of the upper esophagus shows leakage of contrast material after instrumentation.
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Media type:  X-RAY

Media file 5:  Cervical abscess following esophageal injury subsequent to endotracheal intubation. Note the increased soft tissue prevertebral space and air in the soft tissues (see also Image 6).
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Media type:  X-RAY

Media file 6:  Cervical abscess following esophageal injury subsequent to endotracheal intubation. Note the increased soft tissue prevertebral space and air in the soft tissues (see also Image 5).
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Media type:  X-RAY

Media file 7:  Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows a false tract emanating from the esophagus (arrow).
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Media type:  CT

Media file 8:  Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows leakage of oral contrast material (blue arrow) and air in the posterior mediastinum (red arrow).
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Media type:  CT

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

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Article Last Updated: Jul 20, 2005