(See also Overview of Esophageal and Swallowing Disorders Overview of Esophageal and Swallowing Disorders The swallowing apparatus consists of the pharynx, upper esophageal (cricopharyngeal) sphincter, the body of the esophagus, and the lower esophageal sphincter (LES). The upper third of the esophagus... read more .)
Endoscopic procedures are the primary cause of esophageal rupture, but spontaneous rupture may occur, typically related to vomiting, retching, or swallowing a large food bolus.
Spontaneous rupture is especially likely in patients who have untreated eosinophilic esophagitis .
The most common site of rupture is the distal esophagus on the left side. Acid and other stomach contents cause a fulminant mediastinitis and shock. Pneumomediastinum Pneumomediastinum Pneumomediastinum is air in mediastinal interstices. The main causes of pneumomediastinum are Alveolar rupture with dissection of air into the interstitium of the lung with translocation to... read more is common.
Symptoms and Signs of Esophageal Rupture
Symptoms of esophageal rupture include chest and abdominal pain, fever, vomiting, hematemesis, and shock. Subcutaneous emphysema is palpable in about 30% of patients. Mediastinal crunch (Hamman sign), a crackling sound synchronous with the heartbeat, may be present.
Diagnosis of Esophageal Rupture
Chest and abdominal x-rays
Chest and abdominal x-rays showing mediastinal air, pleural effusion, or mediastinal widening suggest the diagnosis.
Diagnosis of esophageal rupture is confirmed by esophagography with a water-soluble contrast agent, which avoids potential mediastinal irritation from barium. CT of the thorax detects mediastinal air and fluid but does not localize the perforation well. Endoscopy may miss a small perforation.
Treatment of Esophageal Rupture
Endoscopic stenting or surgical repair
Pending surgical repair or endoscopic stenting, patients should receive broad-spectrum antibiotics (eg, gentamicin plus metronidazole or piperacillin/tazobactam) and fluid resuscitation as needed for shock. Even with treatment, mortality is high.