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Esophageal Perforation

Esophageal Perforations


Presentation

  • 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]
  • The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient.[ncbi.nlm.nih.gov]
  • We presented two cases of delayed esophageal perforation without obvious cause in two patients who underwent anterior cervical spine surgery and RS use.[ncbi.nlm.nih.gov]
  • We present the case of a 72-year-old patient who underwent ACDF due to cervical spondylosis 25 years ago. Delayed esophageal perforation occurred 20 years postoperatively and healed spontaneously with conservative treatment.[ncbi.nlm.nih.gov]
  • This case describes the workup and management of a patient who presented with recurrent deep neck space infection following anterior cervical spine surgery.[ncbi.nlm.nih.gov]
Fever
  • On physical examination, general weakness, chest pain, odynophagia, and a fever up to 38.9 C were found.[ncbi.nlm.nih.gov]
  • Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury.[ncbi.nlm.nih.gov]
  • […] life-threatening because it is very frequently misdiagnosed and appropriate management is often delayed.A 49-year-old man presented with worsening sudden-onset interscapular back pain that then changed to chest pain with odynophagia and was found to have fever[ncbi.nlm.nih.gov]
  • Following the tracheostomy, the patient developed intractable fevers and nonspecific symptoms. A CT scan demonstrated frontal pneumocephalus without mass effect. Air was found in the retropharyngeal space.[ncbi.nlm.nih.gov]
  • METHODS: A 49-year-old man with severe upper thoracic back pain and intermittent fever was referred to our hospital. Five months before presentation, the patient was diagnosed with compression fracture of T2 vertebra with a teardrop fragment.[ncbi.nlm.nih.gov]
Recurrent Infection
  • Five years later, a second esophageal perforation occurred, which required surgical intervention and involved recurrent infection. We suggest that it is important to consider follow-up in patients with spontaneously healed esophageal perforations.[ncbi.nlm.nih.gov]
  • The purpose of this study is to report a case of recurrent infection after anterior cervical decompression and fusion suspected to have resulted from direct communication between the oropharynx and deep neck space. This study is a case report.[ncbi.nlm.nih.gov]
Soft Tissue Swelling
  • Prevertebral soft-tissue swelling (PSTS) after anterior cervical spine surgery may result in postoperative catastrophic airway complications and persistent dysphagia.[ncbi.nlm.nih.gov]
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]
  • Chest radiography and computed tomography (CT) revealed a massive left pleural effusion and left tension pneumothorax. Abdominal CT revealed pyloric stenosis with a remarkably dilated stomach.[ncbi.nlm.nih.gov]
  • Based upon the autopsy and histopathological findings, as well as the biochemical and toxicological analyses, we concluded that the cause of death was respiratory failure by pleural effusion, resulting from spontaneous esophageal perforation.[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]
  • Imaging: CXR: may demonstrate pneumomediastinum, pneumothorax, subcutaneous emphysema, or pleural effusion. Gastrograffin esophagram (ED test of choice): esophageal irregularity or extravasation of contrast.[emdocs.net]
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]
  • 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]
  • 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]
Cough
  • The patient reported a short coughing episode while eating rice, and his mother performed the Heimlich maneuver on him.[ncbi.nlm.nih.gov]
  • 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]
  • […] 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]
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]
  • We report on a case of IED caused by repeated vomiting due to a small bowel obstruction associated with a small amount of pneumomediastinum on CT. IED has traditionally been believed not to be associated with esophageal perforation.[ncbi.nlm.nih.gov]
  • Rarely, pre-pyloric gastric cancer can present with Boerhaave syndrome, spontaneous esophageal perforation associated with forceful vomiting.[ncbi.nlm.nih.gov]
  • It typically occurs after vomiting or straining as the increased intra-abdominal pressure transmits into the esophagus and results in the tear. One of the main complications is acute bacterial mediastinitis from contamination with esophageal flora.[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]
Dysphagia
  • Retropharyngeal steroids have been shown to decrease PSTS and dysphagia after anterior cervical spine surgery.[ncbi.nlm.nih.gov]
  • A 53-year-old man was admitted because of progressive dysphagia and retrosternal pain for 20 days. Esophagogastroduodenoscopy showed an irregular submucosal bulge on the distal esophageal wall.[ncbi.nlm.nih.gov]
  • Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury.[ncbi.nlm.nih.gov]
  • After 2-years of follow-up the patient continues to have no sequelae from the perforation or symptoms of dysphagia, while Excess Weight Loss is 74.[ncbi.nlm.nih.gov]
  • They did not complain any reflux symptom or dysphagia for 9 to 13 months after operation.[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]
  • Five days later, he presented to the emergency department with throat pain, odynophagia, secretion intolerance, muffled voice, and neck stiffness. He was admitted to the pediatric intensive care unit for conservative management.[ncbi.nlm.nih.gov]
  • Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury.[ncbi.nlm.nih.gov]
  • This condition can be life-threatening because it is very frequently misdiagnosed and appropriate management is often delayed.A 49-year-old man presented with worsening sudden-onset interscapular back pain that then changed to chest pain with odynophagia[ncbi.nlm.nih.gov]
  • Neck/chest pain, odynophagia, and dysphagia were the most common presenting symptoms--each occurring in the majority of patients. Where reported, diagnostic sensitivity of lateral neck X-rays was 56%, and computed tomography (CT) scan was 100%.[ncbi.nlm.nih.gov]
Abdominal Pain
  • History of present illness: A 51-year-old male with history of gastroesophageal reflux disease status post multiple endoscopies presented to the emergency department with severe abdominal pain.[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]
  • The increasing use of imaging technology in the evaluation of patients with acute chest or abdominal pain in most emergency rooms, in particular CT scans, often leads to previously unexpected findings suggestive of esophageal perforation.[clinicaladvisor.com]
  • An acute abdominal pain appeared on the 6th p.o.d. Abdominal palpation revealed tenderness and guarding. A CT scan showed a mediastinal abscess, a right pleural effusion associated with a pneumoperitoneum and peritoneal effusion.[ejcts.oxfordjournals.org]
Epigastric Pain
  • Mid-thoracic esophageal perforation presents with subternal or epigastric pain; mediastinal crunch is rarely auscultated. Mackler’s triad.[clinicaladvisor.com]
  • 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]
  • The patient went back to conscious after the CPR and started to complain an abdominal bloating and an epigastric pain. On examination, the patient had a temperature of 36.2 C, blood pressure of 175/110 mmHg, and a heart rate of 81 bpm.[austinpublishinggroup.com]
  • Pain is usually felt as sharp epigastric pain in anterior perforations or as dull epigastric pain with radiation to the back in posterior perforations.[link.springer.com]
  • PRESENTATION • Intra-thoracic perforation • Chest, back, or epigastric pain • Dysphagia • Odynophagia • Dyspnea • Hematemesis • Cyanosisdr.basit@live.com 34. • Intra-abdominal perforation • Epigastric, chest pain • Hematemesis • Epigastric tenderness[slideshare.net]
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]
  • On physical examination, general weakness, chest pain, odynophagia, and a fever up to 38.9 C were found.[ncbi.nlm.nih.gov]
  • On long-term follow-up, 30 % complication rates were encountered; 3 (15 %) stent migrations, 2 (10 %) patients presented with hematemesis, and 1 (5 %) with chest pain.[ncbi.nlm.nih.gov]
  • He was judged to be stable and was discharged again, but returned 2 days later with chest pain.[ncbi.nlm.nih.gov]
  • 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]
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]
  • 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]
  • 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]
  • 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 dr.basit@live.com 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
  • chest pain, which is sudden onset.[explainmedicine.com]
  • PRESENTATION • Retrosternal chest pain • Dysphagia dr.basit@live.com 4. PAST HISTORY • APD dr.basit@live.com 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]
Chest Deformity
  • A 65-year-old man with a history of ankylosing spondylitis presented with severe dysphagia 1 year after C7 pedicle subtraction osteotomy, C2-T4 posterior instrumentation, and C6-C7 ACDF with a plate for a chin-on-chest deformity.[ncbi.nlm.nih.gov]

Workup

  • 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]
  • Esophageal perforation was diagnosed radiographically during workup for acute chest pain in a 67-year-old man. Emergent endoscopy confirmed esophageal perforation and biopsied a pre-pyloric mass confirmed to be adenocarcinoma.[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]
  • Chest radiography and computed tomography (CT) revealed a massive left pleural effusion and left tension pneumothorax. Abdominal CT revealed pyloric stenosis with a remarkably dilated stomach.[ncbi.nlm.nih.gov]
  • Based upon the autopsy and histopathological findings, as well as the biochemical and toxicological analyses, we concluded that the cause of death was respiratory failure by pleural effusion, resulting from spontaneous esophageal perforation.[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]
  • Imaging: CXR: may demonstrate pneumomediastinum, pneumothorax, subcutaneous emphysema, or pleural effusion. Gastrograffin esophagram (ED test of choice): esophageal irregularity or extravasation of contrast.[emdocs.net]

Treatment

  • Surgical treatment failed in 29 cases (37.2%).[ncbi.nlm.nih.gov]
  • These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.[ncbi.nlm.nih.gov]
  • Cervical esophageal perforation with abscess formation can be usually treated with conservative treatments of simple drainage and antibiotics. Aggressive surgical treatments are considered if conservative treatments fail.[ncbi.nlm.nih.gov]
  • KEYWORDS: Esophageal perforation; Esophageal stent placement; Hybrid treatment strategy[ncbi.nlm.nih.gov]
  • While conservative treatment has become a more common choice, surgical treatment of perforations is sometimes required, especially for large perforations.[ncbi.nlm.nih.gov]

Prognosis

  • 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]
  • Patients with MNGIE syndrome and chronic intestinal pseudo-obstruction have a particularly poor prognosis and they usually die around 40 years of age. Gastrointestinal perforation associated with MNGIE is extremely rare.[ncbi.nlm.nih.gov]
  • 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]

Etiology

  • 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]
  • The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 28-year period, to characterize optimal treatment options in this severe disease.[ncbi.nlm.nih.gov]
  • This article discusses the etiology, clinical manifestations, and diagnosis of EP, as well as nursing care for patients with EP.[ncbi.nlm.nih.gov]
  • The distal esophagus was the site of perforation in 63% of the patients, and the duration of time between perforation and treatment was CONCLUSION: Our study highlights the importance of considering the etiology of a perforation when planning management[ncbi.nlm.nih.gov]
  • When endoscopic management is used to treat patients with Boerhaave syndrome, it may be beneficial to examine the entire stomach to evaluate for malignant etiology.[ncbi.nlm.nih.gov]

Epidemiology

  • 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]
Sex distribution
Age distribution

Pathophysiology

  • 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]

Prevention

  • Effective strategies to prevent such complications are discussed.[ncbi.nlm.nih.gov]
  • Surgery was mandatory in this case, with the extraction of the bone and double-layer suture, which did not prevent the appearence of an esophageal leakage more than two weeks postoperatively, which was treated conservatively.[ncbi.nlm.nih.gov]
  • Preventive strategies including intravenous steroids for the first 2 to 3 weeks and divided doses of pills should be considered for such patients.[ncbi.nlm.nih.gov]
  • It serves as a caution that a first complication such as hematoma in anterior cervical corpectomy with fusion should be given enough attention to prevent further complications.[ncbi.nlm.nih.gov]
  • An individualized approach for each patient should be chosen to prevent septic complications of this potentially fatal disease.[ncbi.nlm.nih.gov]

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