History

Fact Explanation
Dysphagia Patients can present with dysphagia and or odynophagia. [3]
History of ingestion of a foreign body Ingestion of foreign bodies (bones, coins, button batteries) is one of the most common causes for esophageal perforation. Foreign bodies can cause esophageal perforation either due to pressure effects, release of chemicals (button batteries) or during the endoscopic removal of the foreign body. The commonest sites of perforation are at the level of cricopharyngeus, the crossing of the left mainstem bronchus or aortic arch, and the gastroesophageal junction because these three sites are the narrowest points of the esophagus,This should be suspected especially in toddlers and children. [1]
Pain Patients complain of throat or retrosternal chest pain, which is sudden onset. Pain radiates to the back or to the left shoulder. Perforation of the cervical esophagus causes neck pain. [4] Perforation of the thoracic esophagus leads to mediastinitis and pericarditis. Patients with these complications also can have chest pain. [1,2,3]
History of excessive vomiting or severe retching Patients with excessive vomiting or retching can develop esophageal perforation due to development of increased intraluminal pressure against a closed glottis (Boerhaave syndrome). [4]
History of esophageal instrumentation Patients who have undergone upper gastrointestinal endoscopy, laparoscopic adjustable silicone gastric banding, endoscopic dilatation of the esophagus and esophageal instrumentation have a small risk of developing esophageal perforation. [2,3,4]
Haematemesis Some ingested foreign bodies can migrate and perforate the esophagus and adjacent vessels, including aorta. This can cause massive haematemesis. Sometimes haematemesis can present after few days of ingestion as well. [1]
Symptoms of subcutaneous emphysema Patients with esophageal perforation can develop subcutaneous emphysema due to the leakage of air into the subcutaneous tissue. Swelling of the affected area and feeling of pressure can be the initial complains. With significant leakage of air patients develop wheezing and difficulty in breathing. Patients can have a triad of symptoms (Mackler triad) which includes, vomiting, chest pain and subcutaneous emphysema. [4]
History of trauma Esophageal perforation can occur due to sharp injuries and due to blunt trauma as well. Distal third of the esophagus is commonly involved in blunt trauma, due to its weakness of the muscular wall. Fracture of the thoracic spine can cause direct injury of the esophagus. Compression of the esophagus can also cause ischemia and rupture of the esophagus following trauma. Penetrating injuries to the chest can damage the cervical and thoracic parts as well. [3,4]
Fever Patients who are not diagnosed to have esophageal perforation early, and patients who were not treated properly can develop mediastinitis and sepsis. Patients with sepsis can have fever. [3]
References
  1. TSALIS KONSTANTINOS, BLOUHOS KONSTANTINOS, KAPETANOS DIMITRIOS, KONTAKIOTIS THEODORE, LAZARIDIS CHARALAMPOS. Conservative management for an esophageal perforation in a patient presented with delayed diagnosis: a case report. Array [online] 2009 December [viewed 06 August 2014] Available from: doi:10.1186/1757-1626-2-164
  2. ARDENGH JOSé CELSO, DOMENE CARLOS EDUARDO, VALIATI LOANA HEUKO, MORRELL ALEXANDER CHARLES. Conservative management of esophageal perforation following obesity surgery. Sao Paulo Med. J. [online] 2006 November, 124(6):340-342 [viewed 06 August 2014] Available from: doi:10.1590/S1516-31802006000600008
  3. STRAUSS DIRK C, TANDON RUCHI, MASON ROBERT C. Distal thoracic oesophageal perforation secondary to blunt trauma: Case report. World J Emerg Surg [online] 2007 December [viewed 07 August 2014] Available from: doi:10.1186/1749-7922-2-8
  4. SøREIDE JON, VISTE ASGAUT. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Array [online] 2011 December [viewed 08 August 2014] Available from: doi:10.1186/1757-7241-19-66

Examination

Fact Explanation
Evidence of trauma Patients who sustain traumatic injuries can have bruises or penetrating injuries.
Signs of subcutaneous emphysema Subcutaneous emphysema can develop due to esophageal perforation and leakage of air into the mediastinum. [1] Swelling of the affected area can be seen. Palpation of the affected area will give the sensation of touching tissue paper or Rice Krispies. This is due to movement of air in between the skin and subcutaneous tissue. Narrowing of the upper airway may lead to tachypnea and stridor in severe instances. [2]
Signs of sepsis Patients who develop sepsis are often febrile and ill looking. Low blood pressure, deteriorating overall health of the patient and peripheral vasodilatation leading to warm peripheries can be detected. [2]
References
  1. TSALIS KONSTANTINOS, BLOUHOS KONSTANTINOS, KAPETANOS DIMITRIOS, KONTAKIOTIS THEODORE, LAZARIDIS CHARALAMPOS. Conservative management for an esophageal perforation in a patient presented with delayed diagnosis: a case report. Array [online] 2009 December [viewed 06 August 2014] Available from: doi:10.1186/1757-1626-2-164
  2. STRAUSS DIRK C, TANDON RUCHI, MASON ROBERT C. Distal thoracic oesophageal perforation secondary to blunt trauma: Case report. World J Emerg Surg [online] 2007 December [viewed 07 August 2014] Available from: doi:10.1186/1749-7922-2-8

Differential Diagnoses

Fact Explanation
Acute coronary syndrome Patients with acute coronary syndrome presents with severe chest pain which radiates to the left arm. [2]
Dissecting aortic aneurysm Sudden severe chest pain which radiates to the back is characteristic of dissecting aortic aneurysm. [3]
Traumatic rib fracture Patients can have air in the mediastinum and in the pleural cavity. Chest X-ray will demonstrate the presence of rib fracture. [1]
Peptic ulcer disease Relatively long history of burning epigastric pain is characteristic. Patients usually respond to antacids and proton pump inhibitors. [4]
Pancreatitis Upper abdominal (epigastric or periumbilical) pain, with associated nausea and vomiting. Abdominal pain radiates to the back typically, but may radiates to the chest, flanks, and lower abdomen as well. [5]
Pericarditis Severe and sharp retrosternal chest pain are common presenting complaints, however some patients can be asymptomatic. [6]
Pneumonia Patients with fever, cough, pleuritic type of chest pain are characteristic. [7]
References
  1. STRAUSS DIRK C, TANDON RUCHI, MASON ROBERT C. Distal thoracic oesophageal perforation secondary to blunt trauma: Case report. World J Emerg Surg [online] 2007 December [viewed 07 August 2014] Available from: doi:10.1186/1749-7922-2-8
  2. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 07 August 2014] Available from: doi: 10.1093/eurheartj/ehm355
  3. DE BAKEY M. E., HENLY W. S., COOLEY D. A., CRAWFORD E. S., MORRIS G. C.. Surgical Treatment of Dissecting Aneurysm of the Aorta Analysis of Seventy-Two Cases. Circulation [online] 1961 August, 24(2):290-303 [viewed 08 August 2014] Available from: doi:10.1161/​01.CIR.24.2.290
  4. SCHARSCHMIDT BF. Peptic ulcer disease. Pathophysiology and current medical management. West J Med [online] 1987 Jun, 146(6):724-733 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1307465
  5. CARROLL JK, HERRICK B, GIPSON T, LEE SP. Acute pancreatitis: diagnosis, prognosis, and treatment. Am Fam Physician [online] 2007 May 15, 75(10):1513-20 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555143
  6. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 08 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  7. MARRIE THOMAS J., LAU CATHERINE Y., WHEELER SUSAN L., WONG CINDY J., FEAGAN BRIAN G.. Predictors of Symptom Resolution in Patients with Community‐Acquired Pneumonia. CLIN INFECT DIS [online] 2000 December, 31(6):1362-1367 [viewed 08 August 2014] Available from: doi:10.1086/317495

Investigations - for Diagnosis

Fact Explanation
Water-soluble contrast esophagography This provides the definitive diagnosis of esophageal perforation. False negative results can occur in about 10% to 36% of patients with edema and spasm of the esophagus. The site and the extent of perforation can be detected by leakage of the contrast material. [1,2]
Upper gastrointestinal endoscopy (UGIE) UGIE can also detect the presence of esophageal perforation. [1]
Chest X-ray Chest X-ray shows the presence of air in the mediastinum and pneumothorax in some patients. Subcutaneous emphysema looks like a thin layer of hyperdense shadow just beneath the skin. [2] However if taken early chest X-ray can be normal. If esophageal perforation is strongly suspected despite normal chest X-ray film, it is justified to repeat chest X-ray in few hours intervals. [1]
CT scan CT scan of the chest can detect the presence of air in the mediastinum and subcutaneous emphysema. CT scan is more sensitive in detecting small emphysema than the chest X-ray. [1,2]
References
  1. TSALIS KONSTANTINOS, BLOUHOS KONSTANTINOS, KAPETANOS DIMITRIOS, KONTAKIOTIS THEODORE, LAZARIDIS CHARALAMPOS. Conservative management for an esophageal perforation in a patient presented with delayed diagnosis: a case report. Array [online] 2009 December [viewed 06 August 2014] Available from: doi:10.1186/1757-1626-2-164
  2. STRAUSS DIRK C, TANDON RUCHI, MASON ROBERT C. Distal thoracic oesophageal perforation secondary to blunt trauma: Case report. World J Emerg Surg [online] 2007 December [viewed 07 August 2014] Available from: doi:10.1186/1749-7922-2-8

Investigations - Fitness for Management

Fact Explanation
Full blood count Patients with sepsis can have elevated white blood cell counts (especially neutrophils).
Blood culture If there is a significant risk of sepsis, blood culture is necessary to diagnose or to rule out sepsis.
Renal profile Patients with sepsis can have multi-organ failure leading to deranged renal function. Abnormal electrolyte profile and elevated serum creatinine are common findings. [1]
Liver function test Sepsis is a cause for acute liver failure. Elevated liver enzymes, PT/INR can be found. [2]
References
  1. MAJUMDAR A. Sepsis-induced acute kidney injury Indian J Crit Care Med [online] 2010, 14(1):14-21 [viewed 08 August 2014] Available from: doi:10.4103/0972-5229.63031
  2. BANKS JG, FOULIS AK, LEDINGHAM IM, MACSWEEN RN. Liver function in septic shock. J Clin Pathol [online] 1982 Nov, 35(11):1249-1252 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC497938

Management - General Measures

Fact Explanation
Health education Parents should be advised to observe their children and not to keep coins, button batteries and other stuff within their reach, to minimize the risk of accidental swallowing of foreign bodies. Adults who wear dentures should remove them before going to bed. If accidental ingestion of an object is suspected, they should seek health care facilities as soon as possible.
References

Management - Specific Treatments

Fact Explanation
Conservative management Patients with small perforations, perforation of the cervical esophagus and intrathoracic perforations that are confined to the mediastinum can be managed conservatively. For conservative management patients should be clinically stable and have no evidence of sepsis. Administration of antibiotics, insertion of a nasogastric tube and acid suppression (antacids) are necessary. Patient should be kept nil by mouth. [1]
Insertion of an endoluminal prosthesis This is a novel and minimally invasive treatment option. Insertion of an endoluminal stent and drainage is done. Once the perforation is completely healed, the stent should be removed. [1]
Surgery Early diagnosis and treatment is mandatory and sometimes lifesaving, because complications like sepsis, mediastinitis and pericarditis can develop. Surgical intervention is necessary for patients with perforation of the lower third of the esophagus with pleural, pericardial or peritoneal involvement need surgical repair. [1,2]
References
  1. TSALIS KONSTANTINOS, BLOUHOS KONSTANTINOS, KAPETANOS DIMITRIOS, KONTAKIOTIS THEODORE, LAZARIDIS CHARALAMPOS. Conservative management for an esophageal perforation in a patient presented with delayed diagnosis: a case report. Array [online] 2009 December [viewed 06 August 2014] Available from: doi:10.1186/1757-1626-2-164
  2. ARDENGH JOSé CELSO, DOMENE CARLOS EDUARDO, VALIATI LOANA HEUKO, MORRELL ALEXANDER CHARLES. Conservative management of esophageal perforation following obesity surgery. Sao Paulo Med. J. [online] 2006 November, 124(6):340-342 [viewed 06 August 2014] Available from: doi:10.1590/S1516-31802006000600008