Esophageal perforation is a rare presenting sign of gastric cancer. To date, only nine case reports of this phenomenon have been previously published. [ncbi.nlm.nih.gov]

Published on Oct 13, 2014 Esophageal perforation case presentation and management 1. CASE PRESENTATION [email protected] 2. PRESENTATION • XYZ • 40 Y • Female [email protected] 3. [slideshare.net]

• Fever

  On physical examination, general weakness, chest pain, odynophagia, and a fever up to 38.9°C were found. [ncbi.nlm.nih.gov]

  […] complains of neck or chest pain, rapid heart rate, fever or chills. [memorialhermann.org]

• Fishing

  A 68-year-old man was admitted complaining of substernal pain and dysphagia after ingesting a fish bone. Immediately emergency endoscopy was performed, and the fish bone was observed lodged in the lower esophagus. [ncbi.nlm.nih.gov]

  Closure of an esophageal perforation due to fish bone ingestion by endoscopic clip application. Gastrointest Endosc. 2000;51:736–9. PubMed CrossRef Google Scholar 64. Parupudi VJ, Guduru R, Nageshwar D. [link.springer.com]

• Pleural Effusion

  Computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged again, but returned 2 days later with chest pain. [ncbi.nlm.nih.gov]

  These include: extraluminal gas locules in the mediastinum or abdominal cavity, adjacent to the esophagus are highly suggestive 2,4 pleural or mediastinal fluid pneumomediastinum or pneumothorax pericardial or pleural effusions can be seen Water-soluble [radiopaedia.org]

  Pleural effusions may occur due to relatively lower intrathoracic pressures. Enlarging pleural effusions require chest tube or CT-guided catheter placement for drainage. [medicine.uiowa.edu]

• Dyspnea

  A 45-year-old male presented with left chest pain and dyspnea after forceful vomiting. Chest radiography and computed tomography (CT) revealed a massive left pleural effusion and left tension pneumothorax. [ncbi.nlm.nih.gov]

  The male reports his pain as constant, severe (10/10), and associated with dyspnea, and non-bloody, non-bilious emesis (3 episodes). ROS is remarkable for esophageal dilation performed 36 hours prior to arrival. [emdocs.net]

  If a perforation is not detected during the procedure or operation, the patient may present with neck, chest or epigastric pain, dysphagia or dyspnea 3,4 although symptoms asides from chest pain (present in 70%) are quite variable 5,6. [radiopaedia.org]

  When the patient is out of the operating room Admit to ward Keep NPO Check chest x-ray, soft tissue neck film, look for free air Monitor for fever, tachycardia, dyspnea, dysphagia, Monitor for back and chest pain Monitor for cervical or chest wall crepitus [medicine.uiowa.edu]

  We administered antibiotic treatment, but intermittent fever persisted without improvement, and the patient complained of dyspnea. An increased procalcitonin level on day 12 indicated sepsis. [nature.com]

• Cough

  The patient reported a short coughing episode while eating rice, and his mother performed the Heimlich maneuver on him. [ncbi.nlm.nih.gov]

  […] perforation, and the overall health of the patient. 4 Case Report A 73 year old male was admitted in the Emergency department following referral from a local general practitioner where he initially presented 4 days previously with fever, shortness of breath, cough [jpma.org.pk]

  […] seen anterior to the fusion plate (c) Barium swallow study done ten days postoperatively shows resolution of perforation (d) Click here to view Approximately four months following his surgeries the patient began to develop increased sputum production, cough [ijciis.org]

  These conditions occur during vomiting, straining, coughing, seizing, and weightlifting. The sudden increase in intra-abdominal pressure transmits into the esophagus and results in full-thickness tear of the esophageal wall. [journals.lww.com]

• Dysphagia

  Retropharyngeal steroids have been shown to decrease PSTS and dysphagia after anterior cervical spine surgery. [ncbi.nlm.nih.gov]

• Vomiting

  We report a case of esophageal perforation (Boerhaave syndrome) caused by vomiting related to a duodenal ulcer with pyloric stenosis. A 45-year-old male presented with left chest pain and dyspnea after forceful vomiting. [ncbi.nlm.nih.gov]

  Patients with these complications also can have chest pain. [1,2,3] History of excessive vomiting or severe retching Patients with excessive vomiting or retching can develop esophageal perforation due to development of increased intraluminal pressure [explainmedicine.com]

  Mallory-Weiss Syndrome • Etiopathogenesis: • Forceful vomiting producing a mucosal tear at the cardia; not a full perforation • Vigorous vomiting producing a vertical split in the mucosa • In 90% cases, occurs immediately below the SC junction at the [de.slideshare.net]

• Dysphagia

  Retropharyngeal steroids have been shown to decrease PSTS and dysphagia after anterior cervical spine surgery. [ncbi.nlm.nih.gov]

• Odynophagia

  Two days later, he presented with odynophagia. Computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged again, but returned 2 days later with chest pain. [ncbi.nlm.nih.gov]

• Abdominal Pain

  The patient reported taking Prilosec that morning before eating breakfast, after which he felt like something was stuck in his throat with abrupt onset of abdominal pain radiating to his back and associated dyspnea, described as “the worst pain of my [jetem.org]

  Presentation of Case: A 90 years old female patient admitted to secondary level hospital with chronic abdominal pain, yellow discoloration of skin and sclera. ERCP was planned for differential diagnosis of periampullary tumor. [sciencedomain.org]

  Clinical Presentation: Patients may report pain localized to the chest/midepigastrum or shoulder; abdominal pain, nausea, dysphagia, dyspnea, and/or fever. Evaluation and Treatment: 2,3 Assess the ABCs and obtain VS. [emdocs.net]

  Severe epigastric pain, abdominal rigidity with peritonitis, and, occasionally, pain radiating to the back or left shoulder are hallmarks of the perforation of the abdominal portion of the esophagus. [clinicaladvisor.com]

• Chest Pain

  He did well on follow-up 3 months after hospitalization.The case highlights the importance of considering esophageal etiologies of chest pain. [ncbi.nlm.nih.gov]

  Clinicians should remember the other structures in the chest – if it is a part of the chest, it can be the cause of “chest pain.” [journals.lww.com]

• Tachycardia

  Pertinent physical examination findings: CV: S1, S2, tachycardia, regular rhythm Lungs: Decreased breath sounds R base Abdomen: Soft NT, ND, absent guarding and rebound EKG: Sinus tachycardia, axis WNL, normal intervals, no acute ST-T wave changes CXR [emdocs.net]

  When the patient is out of the operating room Admit to ward Keep NPO Check chest x-ray, soft tissue neck film, look for free air Monitor for fever, tachycardia, dyspnea, dysphagia, Monitor for back and chest pain Monitor for cervical or chest wall crepitus [medicine.uiowa.edu]

  Unconsciousness, hypotension (70/40mmHg), tachycardia (140/min) tachypnea (24/min) were the first presenting symptoms. Body temperature was 38ºC. Generalized tenderness and rigidity were presented during abdominal examination. [sciencedomain.org]

  Intrathoracic and intraabdominal perforations are more severe than cervical perforations and may present with characteristic signs of systemic sepsis such as tachycardia, tachypnea, and fever. 6,3 CT esophagography showing pleural effusions, pneumomediastinum [jetem.org]

  TUBE THORACOSTOMY • Pleural fluid with food debris • Shortness of breath improved but tachycardia worsened (Pulse 110/min) • Low grade fever [email protected] 11. [slideshare.net]

• Hypotension

  Unconsciousness, hypotension (70/40mmHg), tachycardia (140/min) tachypnea (24/min) were the first presenting symptoms. Body temperature was 38ºC. Generalized tenderness and rigidity were presented during abdominal examination. [sciencedomain.org]

  Depending on the time elapsed from the injury and degree of cavitary contamination, signs of systemic inflammatory response, overt sepsis, or shock (tachycardia, tachypnea, hypotension, fever etc.) may appear. [clinicaladvisor.com]

  Patients may also present with odynophagia, dyspnea, tachypnea, cyanosis, tachycardia, fever, and hypotension which may develop within hours of the perforation. [journals.lww.com]

  In contrast, thoracic esophageal perforation results in rapid mediastinal contamination and often violation of the mediastinal pleura, which initiates a powerful, cytokine-mediated fluid sequestration, mediastinitis, sepsis and hypotension. [link.springer.com]

• Retrosternal Chest Pain

  Patients complain of throat or retrosternal chest pain, which is sudden onset. [explainmedicine.com]

  PRESENTATION • Retrosternal chest pain • Dysphagia [email protected] 4. PAST HISTORY • APD [email protected] 5. [slideshare.net]

• Mediastinal Crunch

  Mid-thoracic esophageal perforation presents with subternal or epigastric pain; mediastinal crunch is rarely auscultated. Mackler’s triad. [clinicaladvisor.com]

Workup of the second infection found a subtle cortical breach in the mandible at the site of prior invasive dental work. [ncbi.nlm.nih.gov]

Laboratory workup revealed leukocytosis of 14,640/μL with a predominance of neutrophils (82.4%). Electrocardiogram, chest radiograph, and serum Troponin T were normal. [journals.lww.com]

• Pneumoperitoneum

  Despite there are few reports of massive gastric distension causing gastric rupture and pneumoperitoneum after CPR, pneumoperitoneum and esophageal rupture has been rarely reported. [austinpublishinggroup.com]

  Five patients required additional interventions: four tube thoracostomies for pneumothoraces and one peritoneal drain for pneumoperitoneum. [ncbi.nlm.nih.gov]

  A CT scan showed a mediastinal abscess, a right pleural effusion associated with a pneumoperitoneum and peritoneal effusion. Then the patient was transferred to us. [ejcts.oxfordjournals.org]

• Pleural Effusion

  Computed tomography demonstrated small bilateral pleural effusions. He was judged to be stable and was discharged again, but returned 2 days later with chest pain. [ncbi.nlm.nih.gov]

  These include: extraluminal gas locules in the mediastinum or abdominal cavity, adjacent to the esophagus are highly suggestive 2,4 pleural or mediastinal fluid pneumomediastinum or pneumothorax pericardial or pleural effusions can be seen Water-soluble [radiopaedia.org]

  Pleural effusions may occur due to relatively lower intrathoracic pressures. Enlarging pleural effusions require chest tube or CT-guided catheter placement for drainage. [medicine.uiowa.edu]

KEYWORDS: Esophageal perforation; Esophageal stent placement; Hybrid treatment strategy [ncbi.nlm.nih.gov]

Surgical Treatment Surgical treatment includes repair of the hole in the esophagus, coverage of the repair with healthy muscle and drainage of the fluid around the esophagus. [memorialhermann.org]

The prognosis after perforation was poor. © The Author 2014. Published by Oxford University Press on behalf of The Japan Radiation Research Society and Japanese Society for Radiation Oncology. [ncbi.nlm.nih.gov]

Mortality/Morbidity Prognosis The prognosis can be poor, especially if diagnosis is delayed. Even with prompt diagnosis and definitive therapy, the hospital course may be prolonged with high rates of morbidity and mortality. [emedicine.medscape.com]

Treatment and prognosis There is a high mortality rate, estimated between 25 to 50% in some series 1,4 and this is significantly increased if the diagnosis is delayed beyond 24 hours 6. [radiopaedia.org]

Outlook (Prognosis) The condition can progress to shock, even death, if untreated. Outlook is good if the problem is found within 24 hours of it occurring. Most people survive when surgery is done within 24 hours. [nicklauschildrens.org]

Factors associated with choice of treatment were age (P < 0.0005), Charlson Index (P = 0.032), etiology (P < 0.0005), and location (P = 0.005). [ncbi.nlm.nih.gov]

ETIOLOGY • More than one half of all esophageal perforations are iatrogenic and most of these occur during endoscopy Merchea A, Cullinane DC, Sawyer MD, et al. [slideshare.net]

Answer: Esophageal Perforation 1-3 Epidemiology : Most frequent etiology: iatrogenic injury following upper endoscopy and transesophageal echo (TEE) (60%). 1 May also occur secondary to retching (Booerhave’s syndrome), caustic ingestion, trauma, foreign [emdocs.net]

14% of people. [6] Pain can occasionally radiate to the left shoulder, causing physicians to confuse an esophageal perforation with a myocardial infarction. [ citation needed ] It may also be audibly recognized as Hamman's sign. [ citation needed ] Pathophysiology [en.wikipedia.org]

Effective strategies to prevent such complications are discussed. [ncbi.nlm.nih.gov]

Prevention These injuries are hard to prevent. visHeader References Eckstein M, Henderson SO. Thoracic trauma. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. [nicklauschildrens.org]