Unlike a Mallory-Weiss tear, esophageal ruptures are full thickness tears of the esophagus. Patients usually report forceful vomiting followed by severe chest pain and nausea. Although most papers describe the classic presentation of esophageal rupture as chest pain, and subcutaneous emphysema, patients rarely present with this triad. Additionally, patients have a wide variety of past medical histories and presentations. Thus, diagnosis and recognition of esophageal rupture is difficult and often missed.
Patients usually suffer severe complications including mediastinitis, empyema, sepsis and eventually multi-organ failure. The gold standard for diagnosis has typically been a contrast swallowing study showing leakage of contrast material from the esophagus. However, computed tomography CT Chest is also now considered to be diagnostic as PO contrast can be administered and seen leaking from the esophagus as well.
Additionally, CT Chest is usually more readily available than a swallowing study. The typical patient presents with chest pain and nausea after a fit of forceful, uncoordinating vomiting. Depending on their delay in presentation, patients can also present unstable and in shock.
Patient can present within a few hours of rupture or after a several day delay, accounting for much of the variability in presentation. Given the wide array of symptoms that esophageal rupture can present with, patients can often be misdiagnosed with other disease processes such as pancreatitis, myocardial infarction, acute pulmonary embolus, pericarditis, perforated ulcer and dissecting aneurysm.
Patients may have severe chest pain and subcutaneous emphysema on the chest wall, bone cancer and heart rupture. Esophageal leakage can also lead to mediastinitis, pleural effusion decreased breath sounds at baseand pneumothorax decreased breath sounds with decreased fremitus.
Depending on their clinical status, they may have signs and symptoms of sepsis. The gold standard diagnostic tool thus far has been a contrast swallowng study showing leakage of contrast material from the esophagus.
More recently, however, CT Chest is becoming a more readily available diagnostic option with likely equally as reliable results. CXR can also be done as an initial evaluation, however, it is often normal even in the presence of esophageal rupture.
When it is abnormal, you may see evidence of a pleural effusion usually left sided or atelctasis and pneumothorax. There are no laboratory tests to diagnose esophageal rupture.
However, lab studies are needed to help rule out other causes of the patients symptoms, such as cardiac enzymes for chest pain and concern for MI, pancreatic enzymes for epigastric pain and concern for pancreatitis. A CBC may demonstrate a leukoctosis which would not be diagnostic for esophageal rupture, but can be increased in patients with extensive infectious complications from rupture.
It is important to note, however, that patients can present with completely normal lab values, or can present with abnormal tests consistent with sepsis. CXR - a good initial evaluation tool, however, it is normal in post patients. When abnormal, you may see left bone cancer and heart rupture effusion, atelectasis, pneumothorax or pneumomediastinum. Oral contrast swallowing study - you can see leakage of the contrast from the esophagus into the mediastinum or pleural space.
CT Chest - may show full thickness tear of the esophagus with leakage of contrast into the mediastinum, pneumomediastinum, bone cancer and heart rupture, as well as the same lung pathology that can be seen bone cancer and heart rupture CXR.
The first priority for management is stabilizing the patient if they are unstable and getting them to the appropriate next level of care such as the ICU. Patients usually need to have an NG tube placed to intermittent suction, broad spectrum antibiotics initiated, and parenteral nutrition initiated once they are stabilized and adequate access is obtained.
Physical exam is important to assess for signs of severe comorbidities such as pneumomediastinum, bone cancer and heart rupture, or severe sepsis as bone cancer and heart rupture would all require immediate management. Treatment plans should be developed in conjunction with the GI and surgery subspecialty services.
Treatment can be conservative, with antibiotics with or without more aggressive therapy with primary surgical repair of the rupture or secondary isolation of the esophagus from the stomach to prevent leakage of additional gastric contents into the mediastinal space. It is important to note that if patients are treated conservatively and start to show signs of decline, they will likely need surgical repair. Older studies demonstrated higher mortality rates for patients treated conservatively or with delayed surgical repair, bone cancer and heart rupture, however, newer case reports describe more similar outcomes with conservative management when primary repair is not possible or delayed.
If esophageal rupture occurs at or near the site of an esophageal malignancy, the patient will likely need esophageal resection, bone cancer and heart rupture. Stable patients can rapidly become unstable at any point in their hospitalization. Therefore when transitioning care of the patient when you leave the hospital, it is important to give the on-call team a plan for what to expect and what to do if the patient decompensates as it will likely involve other services such as GI and surgery.
Diagnosis and surgical management. Literature review and treatment algorithm. A review of management and outcome. Interact Cardiovasc Thorac Surg. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC.
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