Esophageal rupture
Esophageal rupture is a full-thickness tear of the esophageal wall, most often iatrogenic after endoscopy or spontaneous (Boerhaave syndrome) from forceful vomiting, that spills contaminated contents into the mediastinum and causes rapidly fatal mediastinitis and sepsis without emergent source control. CT with oral water-soluble contrast or a contrast esophagram confirms the leak, and treatment combines resuscitation, broad-spectrum antimicrobial therapy, and either emergent surgical repair or endoscopic stenting depending on the size, location, and time since perforation.
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What this article covers
- Overview
Definition: esophageal rupture is a full-thickness (transmural) perforation of the esophageal wall that spills saliva, gastric contents, and swallowed bacteria into the mediastinum, pleural space, or neck.
- Epidemiology
Iatrogenic perforation is the leading cause, accounting for more than half of cases, classically following upper endoscopy, dilation, biopsy, or tube placement.
- Risk factors
Recent esophageal instrumentation: upper endoscopy, therapeutic dilation of a stricture or achalasia, endoscopic biopsy, variceal banding or sclerotherapy, and transesophageal echocardiography.
- Pathophysiology
Sudden pressure gradient tears the wall: in Boerhaave syndrome, forceful vomiting against a closed upper esophageal sphincter raises intraluminal pressure far above what the wall can withstand…
- Clinical features
Sudden severe retrosternal or epigastric chest pain, often radiating to the back or shoulder, worsened by swallowing or breathing, classically beginning during or right after forceful vomiting or retching.
- Differential diagnosis
Mallory-Weiss syndrome: a mucosal/submucosal (not full-thickness) laceration at the gastroesophageal junction from forceful vomiting, presenting with hematemesis rather than chest pain, subcutaneous…
- Diagnosis
Confirm with CT of the chest and abdomen using oral water-soluble contrast, or a contrast esophagram, showing extraluminal contrast, an esophageal wall defect, pneumomediastinum, or a…
- Management
Resuscitate immediately, make the patient NPO, and involve surgery emergently: large-bore IV access, aggressive isotonic crystalloid resuscitation for hypotension or sepsis, nasogastric decompression…
- Complications
Mediastinitis and septic shock: the dominant cause of death, arising from unchecked contamination of the mediastinum by oral and gastric flora and digestive enzymes.
- Prognosis
Time to treatment is the dominant prognostic factor: mortality is substantially lower when diagnosis and source control occur within 24 hours of the perforation and rises sharply with any delay beyond that window.
- Prevention
Careful, experienced technique during upper endoscopy, dilation, and biopsy, using graduated, size-appropriate dilators and avoiding forceful passage through a tight stricture or angulated segment…
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