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Oesophageal emergencies

Explore the challenges of oesophageal injuries like perforation, Boerhaave syndrome, and diagnostic techniques. Learn about underlying disorders, clinical presentations, and common misdiagnoses requiring urgent surgical intervention.

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Oesophageal emergencies

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  1. Oesophagealemergencies Pál Ondrejka Professor of Surgery

  2. Emergencyoeasophagealdisorders • Perforation • Iatrogenicperforation • Spontaneousperforation • Boerhaave’ssyndrome • Traumaticperforation • Blunt trauma • Penetratinginjuries • Foreign body • Causticinjuries • Alcalic • Acidic

  3. Whytheoesophagealinjuriesarehighlyproblematic? • The proximity of vitalstructures • The bloodsuply • The lack of serosalsurfacearroundtheorgan • The injuriesarecarryhighmorbidity and mortality • Most surgeons has limited experienceswithdiagnosis and treatment of suchcases

  4. Hermann Boerhaave(31 December 1668 – 23 September 1738)[

  5. Boerhaave syndrome • Boerhaave first described Boerhaave syndrome, which involves tearing of the oesophagus, usually a consequence of vigorous vomiting. He notoriously described in 1724 the case of Baron Jan van Wassenaer, a Dutch admiral who died of this condition following a gluttonous feast and subsequent regurgitation.[8] This condition was uniformly fatal prior to modern surgical techniques allowing repair of the oesophagus.

  6. Aetiology • Suddenrise of intra-abdominalpressure (80-90%) • Vomitingorretching • Blunt trauma • Weightlifting • Defecation • Heimlich manoeuvre • Status epilepticus

  7. Existingunderlyingoesophagealdisorders (10-20%) • Malignancy • Pepticulceration • Herpessimplexvirus (HSV) • Human immunodeficiencyvirus (HIV) • Tuberculosis (TB)

  8. Tipicallocation • Justabovethediaphragm • Leftposterolateralposition • Usuallysingl, longitudinal, 1-8 cm • Men : women = 4 . 1 • Medianage 64 years • Most of thambecauseofalcoholicintoxication • Pleuraldisruptiondevelopesbarogenicallyorfrom rapid gastricaciderosion

  9. Mackler’striadofclinicalpresentation of oesophagealperforation • Vomitingorretching • Chestpain (Sudden and dramatic) constant, epigastricorretrosternal, exacerbatedbymovement • Subcutaneousemphisema (takesabout an hourtodevelop)

  10. Othersymptomes • Tachycardia, tachypnoe • The patienttakessitingpositioninordertoreducediaphragmaticmovements • Patientsarepale and sweaty • Coolperipheries • Chemicalpleuromediastinitisdevelops • In 24.48 hourscardiopulmanaryinsuffitientydevelops

  11. Diagnosticexaminations • Plainchest and abdominalradiography • Contrastradiography • Uppergastrointestinalendoscopy • Computedtomography (CT) • Other • Pleuralaspiration • Oralbluedyes

  12. Plainchestradigraphy

  13. Tipicalchestradiographyfindings • Pleuraleffusion • Pneumomediastinum • Sucutaneousemphysema • Hydropneumothorax • Pneumothorax

  14. Preoperativeresustitation • Control of airway and administration of O2 • Earlyanaestheticinvolvment • Stabilecentralintravenosusaccess • Urethralcatether • Broadspectrumantibiotic and antifungalagents • Intravenosusantisecretorydrugs • Zerodiet • Intercostalchestdrainage • Nasogastrictube

  15. Contrastradiograpy

  16. Endoscopicexamination

  17. CT scan

  18. Frequentmedicalmisdiagnoses • Myocardialinfarction • Pericarditis • Spontaneouspneumothorax • Pneumonia • Oesophagealvarices/mallory-Weistear • Mesentericischaemia

  19. Frequentsurgicalmisdiagnoses • Peritonitis • Acutepancreatitis • Perforatedpepticulcer • Renalcoloc • Aorticaneurism (dissection/rupture) • Billiarycolic • Mesentericischaemia

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