Related Subjects:
|Assessing Chest Pain
|Achalasia
|Oesophageal Carcinoma
|Diffuse Oesophageal spasm
|Diffuse Oesophageal Perforation - Rupture
|Gastro-Oesophageal Reflux
|Barrett's oesophagus
⚡ Oesophageal Perforation is a surgical emergency with high mortality if untreated.
🔑 Mackler’s Triad (vomiting, chest pain, subcutaneous emphysema) = classic but only seen in ~50%.
💡 Always think of oesophageal perforation after forceful vomiting (Boerhaave’s) or endoscopic procedures.
| Oesophageal Perforation: Emergency Actions |
|---|
- 🔄 ABC Resuscitation: Secure airway, IV access, fluids, oxygen. Reverse coagulopathy.
- 💉 Broad-spectrum IV antibiotics: Cover anaerobes, Gram +/−.
- 🚫 NPO (nil by mouth): Avoid oral intake. ⚠️ Do NOT insert NG tube unless under specialist guidance.
- 🍴 Consider TPN if prolonged NPO expected.
- 👨⚕️ Early cardiothoracic surgical input:
– Conservative (small contained leak, stable).
– Surgical repair/resection (large tear, unstable).
– Endoscopic stenting/clipping in selected patients.
- 🏥 ICU care: for monitoring, organ support, and sepsis management.
|
📖 About
- Oesophageal perforation = rupture/tear of the oesophageal wall → leakage of gastric contents into mediastinum → severe sepsis (mediastinitis).
- Most common cause = iatrogenic (endoscopy, dilatation). Other causes: spontaneous rupture (Boerhaave’s), trauma, malignancy, foreign bodies.
- Mortality remains high despite advances → early recognition and surgical input essential.
🧬 Aetiology
- 🔧 Iatrogenic: Endoscopy, dilatation of strictures (most common).
- 🤮 Boerhaave’s Syndrome: Spontaneous rupture after forceful vomiting, usually left posterolateral lower oesophagus.
- 🔪 Trauma/Malignancy: Sharp object ingestion, corrosives, tumour erosion.
🩺 Clinical Features
- 🚨 Sudden severe chest pain ± back pain, often after vomiting or a procedure.
- 😷 Dysphagia, odynophagia, vomiting, fever, malaise.
- 🌬️ Subcutaneous emphysema (neck/chest) → palpable “crackling” = surgical emphysema.
- ❤️ Hamman’s sign = crunching sound over heart in systole (pneumomediastinum).
- Dyspnoea, haematemesis, shock (late signs).
🔎 Investigations
- 🩻 CXR: Pneumomediastinum, left pleural effusion, pneumothorax. Pleural tap: ↓ pH, ↑ amylase, food debris.
- 💧 Gastrografin swallow: First-line contrast study (water-soluble). Shows leak/extravasation. ⚠️ Avoid barium → risk of mediastinitis.
- 🖥️ CT chest/abdomen with contrast: Highly sensitive for perforation, air/fluid collections, and extent of leak. Next step if swallow is negative.
- ⚠️ OGD: Avoid unless specialist-directed → insufflation may worsen leak.
💥 Complications
- 🔥 Mediastinitis → abscess, sepsis.
- 🌬️ Surgical emphysema.
- 💧 Pleural effusion or empyema.
- ❌ Multiorgan failure, septic shock, death if untreated.
🛠️ Key Management Steps
💡 Teaching Pearls:
– Always suspect after vomiting + chest pain.
– Gastrografin swallow = diagnostic first choice.
– CT scan if swallow negative/contraindicated.
– Antibiotics + surgical input = lifesaving.
– Mortality ↑ dramatically if diagnosis delayed >24 hrs.
