Oesophageal tears

Question 1

What are oesophageal ruptures?

Answer 1

• Ruptures to any part of oesophageal wall
• Complete ruptures have high mortality
• Wide spectrum of severity - superficial Mallory Weiss and full thickness Boerhaaves syndrome

Question 2

What is oesophageal perforation?

Answer 2

• Full thickness rupture of oesophageal wall
• If spontaneous (often due to vomitting) is called Boerhaaves syndrome

Question 3

Consequence of perforation

Answer 3

• Leakage of stomach contents into mediastinum and pleural cavity
• –> severe sepsis, physiological collapse, multi-organ failure and death

Question 4

Common causes of oesophageal perf

Answer 4

• Iatrogenic eg endoscopy
• Severe forceful vomitting - Boerhaave

Question 5

Common site of oesophageal perfs

Answer 5

• Just above diaphragm
• • In left postero-lateral position
• • 2-3cm proximal to gastro-oesophageal junction

Question 6

Symptoms of oesophageal perforation

Answer 6

• Severe sudden onset retrosternal chest pain
• Respiratory distress
• Subcutaneous emyphysema following severe vomitting/retching

Question 7

Triad for oesophageal perf

Answer 7

• Macklers triad
• Vomitting, chest pain and subcutaenous emphysema
• Not seen very often - only 15%

Question 8

Examination of patients with oesphageal perforation

Answer 8

• Critically unwell - features of severe sepsis
• Intra-thoracic occuring so abdominal signs may be absent
• Chest exam - dullness, reduced air entry due to pleural effusion

Question 9

Bedside and bloods for ?oesophageal perf

Answer 9

• FBC
• CRP
• Group and save

Question 10

Imaging for ?oesophageal perf

Answer 10

• Initial usually CXR - pneumomediastinum or intrathoracic air fluid levels
• Urgent CT chest abdomen pelvis + IV and oral contrast - investigation of choice - may show air/fluid in mediastinum/pleural cavity, if leakage of oral contrast into mediastinum = pathognomonic

Question 11

What contrast should be used for oesophageal perf?

Answer 11

• Water soluble contrast - prevent worsening of inflammation due to leakage into thoracic cavity

Question 12

What to do if imaging inconsistent with clinical suspicion of oesophageal perf?

Answer 12

Urgent endoscopy in theatre

Question 13

Management of oesophageal perfs - principles

Answer 13

Sepsis 6 usually as septic - broad spec abx and antifungals
Principles of management are:
* Control oesophageal leak - account for distal obstruction
* Eradication of mediastinal and pleural contamination
* Decompress oesophagus - transgastric drain or endoscopic NG tube
* Nutritional support

Question 14

Surgical management oesophageal perf - principles

Answer 14

• Drainage intrathoracic contamination - via large bore surgical chest drain (under sedation), in theatre or A&E
• Immediate surgery - control leak and washout via thoracoctomy +/- laparatomy depending on site of perf
• On table endoscopy determine site and assess for distal obstruction

Question 15

Surgical options oesophageal perf

Answer 15

• Primary repair
• Resection
• Diversion/exteriorisation via oesophagectomy
• Or washout and place drains

Question 16

What should all patients have post surgery for oesophageal perf?

Answer 16

• Repeat CT scan with oral contrast as leakage is common - at 10-14 days before restarting oral intake
• May need jejunostomy for feeding at time of initial surgery

Question 17

Non-operative management oesophageal perf - when

Answer 17

• Iatrogenic perforations - more stable than spontaneous
• Minimal contamination
• Contained perforation
• No symptoms/signs of mediastinitis
• Too frail or extensive co-morbids for surgery

Question 18

Why are iatrogenic perfs more stable than spontaneous?

Answer 18

• Patient is usually NBM before procedure so no forceful vomitting associated and not as much contamination

Question 19

Non-operative management oesophageal perf

Answer 19

• Urgent resuscitation and transfer to ICU or high dependency unit
• Abx and antifungal cover
• Endoscopic therapy - clips, covered stents, suturing, vaccum
• NBM - 1-2 weeks, NG tube inserted endoscopically for drainage
• Large bore chest drain - surgical or US guided
• TPN or feeding jejunostomy

Question 20

What are Mallory Weiss tears?

Answer 20

• Lacerations in oesophageal mucosa usually at GOJ
• Tend to occur after period of profuse vomitting and cause short period of haematemesis

Question 21

Management of mallory weiss tears

Answer 21

• Conservative - usually self limiting in absence of clotting abnormalities or anticoags