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Esophageal perforation

Definition

An esophageal perforation is a hole in the esophagus. The esophagus is the tube food passes through as it goes from the mouth to the stomach.

Alternative Names

Perforation of the esophagus

Causes, incidence, and risk factors

The contents of the esophagus can pass into the mediastinum, the surrounding area in the chest, when there is a hole in the esophagus. This often results in infection of the mediastinum (mediastinitis).

The most common cause of an esophageal perforation is injury during a medical procedure. However, the use of flexible instruments has made this problem rare.

The esophagus may also become perforated as the result of:

  • A tumor
  • Gastric reflux with ulceration
  • Previous surgery on the esophagus
  • Swallowing a foreign object or caustic chemicals, such as household cleaners, disk batteries, and battery acid
  • Trauma or injury to the chest and esophagus
  • Violent vomiting

Less common causes include injuries to the esophagus area (blunt trauma) and injury to the esophagus during an operation on another organ near the esophagus.

Symptoms

The main symptom is pain when the problem first occurs.

A perforation in the middle or lower most part of the esophagus may cause difficulty swallowing, chest pain, and breathing problems.

Signs and tests

Signs include:

  • Fast breathing
  • Fever
  • Low blood pressure
  • Rapid heart rate
  • Neck pain or stiffness and air bubbles underneath the skin if the perforation is in the top part of the esophagus .

You may have a chest x-ray to look for air in the soft tissues of the chest, fluid that has leaked from the esophagus into the space around the lungs, or a collapsed lung. X-rays taken after you drink a non-harmful dye can help pinpoint the location of the perforation.

You may also have chest CT scan look for an abscess in the chest or esophageal cancer.

Treatment

You may need surgery, depending on the location and size of the perforation. If surgery is done, it is best to have it within 24 hours of when the perforation occurred.

Treatment may include:

  • Fluids given through a vein (IV)
  • IV antibiotics to prevent or treat infection
  • Draining of fluid around the lungs with a chest tube
  • Mediastinoscopy to remove fluid that has collected in the area behind the breastbone and between the lungs (mediastinum)

If little or no fluid has leaked, a stent may be placed in the esophagus. This may help you avoid surgery.

Sometimes a perforation in the uppermost (neck region) part of the esophagus may heal by itself if you do not eat or drink for a period of time. In this case, you will another way to get nutrients, such as a stomach feeding tube.

Surgery is often needed to repair a perforation in the middle or bottom portions of the esophagus. Depending on the size and location of the perforation, the leak may be treated by simple repair or by removing the esophagus.

Expectations (prognosis)

The condition can progress to shock -- even death -- if untreated.

Outlook is good if the problem is found within 24 hours of it occurring.  Most people survive hen surgery is performed within 24 hours. Survival rate goes down 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

Tell the doctors and nurses right away if you develop the problem when you are already in the hospital.

Go to the emergency room or call 911 if:

  •  You have recently had surgery or a tube placed in the esophagus and you have pain, problems swallowing or breathing
  • You have another reason to suspect that you may have esophageal perforation.

Prevention

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

References

Eckstein M, Henderson SO. Thoracic trauma. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier;2009:chap 42.


Review Date: 10/8/2012
Reviewed By: George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, California. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, David R. Eltz, and Stephanie Slon.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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