Oesophageal Perforation

Question 1

Classification

Answer 1

From within

• swallowed foreign body
• rupture at oesophagoscopy (cricopharyngeus, above stricture)
• rupture during dilatation or biopsy
• rupture during oesophageal echocardiography

From without
- Perforating wound

Spontaneous
- Boerhaave’s syndrome (lower thoracic oesophagus)

Question 2

Clinical feature

Answer 2

After instrumentation

• pain in neck, chest or upper abdomen
• dysphagia
• pyrexia
• subcutaneous emphysema is felt in supraclavicular area

Spontaneous rupture

• vomiting after large meal (Boerhaave’s syndrome)
• severe pain in chest, dorsal region of spine/ upper abdomen (acute mediastinitis)
• collapsed or cyanosed
• abdomen may be rigid
• subcutaneous crepitation is palpable in neck

Question 3

Investigation

Answer 3

• Chest X ray: gas in neck and mediastinum, fluid and gas in pleural cavity
• Thoracoabdominal computed tomography (CT) combined with oral gastrograffin (water soluble contrast fluid): confirm perforation and define its position

Question 4

Treatment

Answer 4

Conservative (cervical perforation)
- parenteral antibiotics, nil by mouth and IV drip

Surgical
Abscess formation in superior mediastinum
- drainage via supraclavicular incision

Thoracic rupture
- immediate suture (or resection if carcinoma is instrumentally perforated)