Oesophageal perforation - Disorders of the oesophagus

Oesophageal perforation

Definition

Perforation of the oesophagus resulting in leakage of the contents.

Aetiology

A rare complication of endoscopy, foreign bodies and trauma. Occasionally a rupture following forceful vomiting may occur (Boerhaave’s syndrome).

Pathophysiology

Perforation usually occurs at the pharyngeooesophageal junction. It results in release of secretions into the mediastinum.

Clinical features

Presentations include surgical emphysema of the neck; intense retrosternal pain, tachycardia and fever in mediastinitis; subdiaphragmatic perforation causes peritonitis.

Investigations

CXR may reveal air in the mediastinum or soft tissues (surgical emphysema).

Management

Small perforations occurring in the neck are managed with broad-spectrum antibiotics and nasogastric tube. Large thoracic perforations are repaired with a gastric fundus patch. Oesophageal perforation secondary to malignancy at or above the lower oesophageal sphincter can be treated with a covered metal stent placed endoscopically.