Perforation - Disorders of the Esophagus

PERFORATION

The esophagus is not an uncommon site of injury. Perforation may result from stab or bullet wounds of the neck or chest, trauma from motor vehicle crash, caustic injury from a chemical burn (described later), or inadvertent puncture by a surgical instrument during examination or dilation.

Clinical Manifestations

The patient has persistent pain followed by dysphagia. Infection, fever, leukocytosis, and severe hypotension may be noted. In some instances, signs of pneumothorax are observed.

Assessment and Diagnostic Findings

Diagnostic x-ray studies and fluoroscopy are used to identify the site of the injury.

Management

Because of the high risk of infection, broad-spectrum antibiotic therapy is initiated. A nasogastric tube is inserted to provide suction and to reduce the amount of gastric juice that can reflux into the esophagus and mediastinum. Nothing is given by mouth; nutritional needs are met by parenteral nutrition. Parenteral nutrition is preferred to gastrostomy because the latter might cause reflux into the esophagus.

Surgery may be necessary to close the wound, and postopera-tive nutritional support then becomes a primary concern. De-pending on the incision site and the nature of surgery, the postoperative nursing management is similar to that for patients who have had thoracic or abdominal surgery.