Esophageal tear is defined as a breach of the esophageal wall resulting from a mucosal tear, perforation, or rupture. Tears of the esophagus are life-threatening conditions that require prompt diagnosis and emergency treatment. Esophageal perforations allow the upper gastrointestinal (GI) contents to egress from the esophageal lumen into the soft tissues of the neck, the mediastinum and pleural space, the peritoneal cavity, and other possible sites (depending on the location of the injury). If esophageal tears remain untreated, then cervical soft tissue infections, mediastinitis, pleuritis, or peritonitis will develop, followed by systemic sepsis and death.
Esophageal perforations, Mallory-Weiss tears, and esophageal hematomas may result from traumatic injury to the esophagus following instrumentation, such as after gastric lavage or upper GI endoscopy. Recent increases in the use of diagnostic and therapeutic endoscopy and esophageal surgery have made endoscopic instrumentation the most common cause of esophageal rupture.
Boerhaave syndrome, Mallory-Weiss syndrome and rare spontaneous esophageal hematomas are all forms of esophageal tear that usually occur during vomiting. Other precipitating factors of spontaneous tears include straining, hiccupping, coughing, primal scream therapy, blunt abdominal trauma, cardiopulmonary resuscitation, or any event accompanied by a marked and often sudden elevation of abdominal pressure. In a few cases, no apparent precipitating factor can be identified.
Spontaneous rupture of the esophagus is a condition that is still often diagnosed late despite presentations with classic histories and/or abnormal chest radiographs. 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 ruptures.
Conventional radiographs are generally used in the initial assessment of patients with suspected esophageal perforation; this is followed by an oral contrast-enhanced examination, which can be critical in determining the presence and precise location of an esophageal perforation. Conventional radiographs may be normal in up to 10% of patients with esophageal perforations. Endoscopy, oral contrast-enhanced studies, and angiography are invasive procedures.
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 scans.
MRI scanning can depict the normal esophageal and mediastinal anatomy and has been used in the diagnosis of esophageal masses, varices, and esophagitis; however, the role of 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 scanning, and a high signal intensity may be depicted on T2-weighted and proton density–weighted images.
(See the images of esophageal tear below.)
Cervical abscess following esophageal injury subsequent to endotracheal intubation. Note the increased soft tissue prevertebral space and air in the soft tissues (same patient as in previous image).
Early diagnosis and management are imperative to minimize complications of enteric leakage into the thoracic or abdominal cavity and prevent consequent sepsis and multisystem organ failure.
Factors impacting morbidity and mortality include the cause and site of the perforation, the time to diagnosis, and the therapeutic procedure.
Treatment options include observation if contained, endoscopic therapy (usually stent placement) if the perforation is of limited size, or surgical management when a large perforation with gross contamination is present.
Pittsburgh Severity Score
The Pittsburgh Severity Score (PSS) is a clinical score based on preexisting esophageal pathology and clinical findings at the time of presentation. Developed at the Univerity of Pittsburgh and subsequently validated in a separate cohort of patients, PSS has been found to predict the need for surgical management, as well as mortality. All variables are assigned points (range, 1-3) for a possible total score of 18. Points are given to each variable according to the following scale
1 = age >75 years
1 = tachycardia (>100 bpm)
1 = leukocytosis (>10,000 white blood cells/mL)
1 = pleural effusion (on chest radiograph, computed tomography, or barium swallow)
2 = fever (>38.5°C. or 101.3°F)
2 = noncontained leak (on barium swallow or computed tomography)
2 = respiratory compromise (respiratory rate >30 breaths/min)
2 = increasing oxygen requirement (or need of mechanical ventilation)
2 = time to diagnosis >24 hours
3 = presence of cancer or hypotension
A PSS greater than 5 is predictive of a greater than 3-fold increase in the need for surgical management and carries a 27% risk of death; a PSS greater than 9 carries 0% survival. Patients with a true esophageal perforation in whom diagnosis and time to treatment are delayed typically have a higher PSS and poorer outcome.
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