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Esophageal Rupture

Esophageal Rupture. Erin M. Will March 27, 2007. Overview. Esophageal rupture is rare Roughly 300 cases reported per year The diagnosis is commonly missed/delayed Mortality is high Most lethal GI perforation Mortality falls with early dx/intervention. Overview.

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Esophageal Rupture

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  1. Esophageal Rupture Erin M. Will March 27, 2007

  2. Overview • Esophageal rupture is rare • Roughly 300 cases reported per year • The diagnosis is commonly missed/delayed • Mortality is high • Most lethal GI perforation • Mortality falls with early dx/intervention

  3. Overview • Survival depends on rapid dx and surgery • Within 24 hours of rupture: 70-75% survival • Within 25-48 hours: 35-50% survival • Beyond 48 hours: 10% survival

  4. Etiology of Esophageal Rupture • Traumatic Causes (MORE COMMON)1,2: • Endoscopy or dilation procedures • Stent placement most common cause (up to 25% cases) • Vomiting or severe straining • Stab wounds / penetrating trauma • Blunt chest trauma (rarely) • Non-Traumatic Causes (LESS COMMON)1,2: • Neoplasm / Ulceration of esophageal wall • Ingestion of caustic materials

  5. Demographics • Spontaneous rupture: • Middle-aged men • Alcoholics • Hx of recent esophageal instrumentation • Chest Trauma • Penetrating > Blunt

  6. Anatomy • Esophagus lacks serosa • More likely to rupture • Site of rupture: • More commonly on left side • Due to instrumentation: distal esophagus • Spontaneous: posterolateral esophagus • Tears are usually longitudinal

  7. Pathophysiology • Air, Saliva, and Gastric contents released • mediastinitis • pneumomediastinum • empyema • can progress to sepsis, shock, resp failure

  8. Presentation • Pain • lower anterior chest / upper abdomen • may radiate to left shoulder / back • Vomiting >> Hematemesis • hematemesis: think Mallory-Weiss/varices • Dyspnea • Cough (precipitated by swallowing) • Fever

  9. On Exam • Subcutaneous Emphysema • Fever • Tachycardia • Tachypnea • Cyanosis

  10. On Exam… • Upper Abdominal Rigidity • Pneumothorax/Hydrothorax • Respiratory Failure • Sepsis • Shock

  11. Initial Imaging: X-ray • PA and Lateral chest films • Look for: • Hydrothorax (L side > R side) • Pneumothorax • Hydropneumothorax • Pneumomediastinum • SubQ emphysema • Mediastinal widening • Pleural Effusion (L side > R side)

  12. Hydrothorax

  13. Initial Imaging: X-ray • Upright abdominal film • Look for subdiaphragmatic air

  14. Subdiaphragmatic Air

  15. Interventional Imaging • Look for extravasation of contrast • Evaluate location and size of rupture • Options • Gastrografin Study • Water-soluble contrast • Barium Esophagram • Positive in 22% of pts with non-diagnostic Gastrografin study results

  16. Interventional Imaging • Do not perform contrast studies on sedated patients • Pt should have intact gag reflex • May choose to use CT if pt is sedated

  17. Gastrografin extravasation

  18. CT scan • Should be used if interventional study: • Cannot be performed (sedation, etc) • Cannot localize rupture or is nondiagnostic • Look for: • Tear in esophageal wall • Pneumomediastinum • Abscess in pleural space or mediastinum • Commuication of esophagus with fluid collections

  19. Pneumomediastinum

  20. What to do next • ICU admission • NPO • NG suction • Broad-spectrum Abx • Want to cover gut bugs • Zosyn is 1st choice • Clinda + Levo is acceptable alternative • Pain control: Narcotics

  21. Indications for conservative mgmt • No clinical signs of infection • Perforation is contained / walled-off

  22. What to do next • Early surgical intervention reduces mortality rate: 1st 24 hours! • “He looks sick!” • “I’m going to call the surgeons!”

  23. Indications for surgery • Sepsis • Respiratory Failure • Shock • Contamination of mediastinum • Associated pneumothorax

  24. Resources 1. eMedicine: Esophageal rupture 2. LearningRadiology.com 3. www.pathology.vcu.edu 4. medscape: esophageal rupture

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