Esophageal trauma can result from numerous etiologies, including iatrogenic injuries from endoscopic instrumentation or other thoracic surgical procedures, penetrating or blunt trauma, caustic ingestion during suicide attempts, and even spontaneously with forceful vomiting or retching (Boerhaave syndrome).^1–3 These traumatic episodes can lead to esophageal perforation—a medical emergency that requires prompt attention. Any delay in diagnosis or treatment leads to increased patient morbidity and mortality. The signs and symptoms of esophageal trauma are presented in this chapter along with recommendations for management.

Esophageal perforation can result from multiple etiologies. Iatrogenic injury is the most common and results as a complication of esophageal instrumentation (50%–70% in modern series).³ Spontaneous rupture, or Boerhaave syndrome, can also occur, typically after prolonged vomiting or retching. Both blunt and penetrating injuries can lead to esophageal perforation (see Chapter 49). For the normal esophagus, the cervical portion is the most common site of injury during instrumentation.^3–7 Middle and distal esophageal injuries usually result from endoscopic stenting or dilation procedures. Iatrogenic injury sustained during endoscopic procedures such as esophagogastroduodenoscopy and transesophageal echocardiography typically are diagnosed more rapidly because the patient is under direct medical observation at the time of the injury. Although rare, esophageal perforation also can result from nasogastric tube placement, esophageal intubation with an endotracheal tube, and nonesophageal surgical procedures performed in proximity to the esophagus, such as tracheostomy, thyroidectomy, various spinal procedures, and mediastinal lymph node dissection during pulmonary resectional procedures.

Spontaneous esophageal rupture, or Boerhaave syndrome, is caused by prolonged forceful vomiting or from abrupt Valsalva-type maneuvers that abruptly increase intrathoracic pressure.^1,3 The perforation in spontaneous cases occurs in the lower esophagus posteriorly into the left chest.

Penetrating injuries to the neck can also lead to esophageal perforation. Owing to proximity to the carotid artery and trachea, penetrating esophageal injury is rarely isolated. Typically, it is associated with more immediate, life-threatening injuries to these adjacent structures.⁶ Blunt neck trauma, which can occur with either powerful direct blows to the neck or more commonly from high-speed motor vehicle accidents, usually causes an intramucosal esophageal hematoma and subsequent dysphagia but rarely perforation. Intramucosal hematomas resolve with expectant management. Full-thickness esophageal injuries can be life threatening and often are missed in this setting, clouded by other more life-threatening injuries with consequent higher morbidity and mortality.^4,6 Full-thickness esophageal injuries are associated with concurrent airway injury. A high index of suspicion is needed when evaluating trauma patients because unrecognized esophageal injury can have disastrous consequences.

Caustic esophageal injury (discussed in detail in Chapter 50) is a form of “chemically” penetrating trauma. It often results from suicide attempts, and the severity of the injury depends on the type, quantity, duration, and for children, taste of the chemical ingested. Alkaline exposure (e.g., lye) is typically more severe than acid (e.g., battery acid or bleach) exposure because alkaline agents cause a liquefactive necrosis, whereas acidic agents lead to a coagulative necrosis.^2,4,8 Treatment of caustic injuries must be expedient to prevent early- and late-term morbidity of this often-fatal injury.

The clinical manifestations of esophageal perforation secondary to blunt or penetrating trauma are nonspecific and depend on the location (i.e., cervical, thoracic, or abdominal esophagus) of injury rather than mechanism. Tachycardia, fever, subcutaneous air, pain, dysphagia, shortness of breath, and listlessness are all nonspecific signs and symptoms of esophageal perforation. Cervical esophageal perforation typically is heralded by neck pain and subcutaneous emphysema involving the neck or upper thorax. Patients with abdominal and thoracic esophageal perforation typically complain of subxiphoid or epigastric pain as well as retrosternal pain occasionally radiating to the back. Tachycardia and dyspnea are uniformly present, leading inevitably to hypotension and shock if the condition is left undiagnosed and untreated.

The need for diagnostic studies depends on the degree of clinical suspicion. In cases of iatrogenic injury, especially those occurring during endoscopy, no further diagnostic studies are needed because the injury is directly visualized. When the presence or nature of esophageal injury is not known, various diagnostic studies can be helpful. In over 90% of patients, chest radiographs will suggest the presence of esophageal injury, with findings of pneumomediastinum, subcutaneous emphysema, and left-sided pleural effusion suggestive of perforation. These findings are nonspecific, however, and an upper gastrointestinal series or chest CT scan with oral contrast material can confirm the diagnosis in over 90% of patients. Water-soluble contrast material is recommended for the upper gastrointestinal series because barium in the mediastinum can cause chemical mediastinitis. Of the two modalities, chest CT scanning is the more sensitive, having been reported to be over 95% sensitive for the diagnosis of esophageal perforation. Esophagogastroduodenoscopy is used in most cases after the injury has been diagnosed by upper gastrointestinal series or chest CT scan.^3,5 Esophagogastroduodenoscopy alone may miss small injuries and potentially can exacerbate the perforation as well as increase mediastinal contamination with air insufflation. Hence its use is limited to the operating room, where it serves as a diagnostic adjunct to precisely map out the area of injury immediately before definitive surgical repair.

Diagnosis of caustic injury rests on the history because it typically occurs after a suicide attempt or accidental ingestion by an infant. Oropharyngeal pain, emesis, and dysphagia are the predominant signs and symptoms. Diagnosis of perforation is made with an upper gastrointestinal series or chest CT scan. If no perforation is seen on upper gastrointestinal series or chest CT scan, esophagoscopy should be performed 12 to 24 hours after initial presentation to examine the extent of esophageal involvement and depth of injury.

The management of esophageal perforation depends on multiple factors, but chief among these are the etiology, location, and time from injury to diagnosis. Progressive delay in diagnosis results in a worsened prognosis because of continued contamination, release of inflammatory mediators, and resulting septic physiology. As expected, iatrogenic perforation typically has the best prognosis because diagnosis is immediate, whereas spontaneous and trauma-related perforations carry the worst prognosis because the diagnosis is often missed and treatment delayed.

Management and survival are both influenced by the anatomic location of the perforation. Cervical esophageal perforations are better contained with less spillage and result in a mortality rate of less than 10%, especially when there is no contamination of the mediastinum. Thoracic and abdominal perforations with widespread contamination of the mediastinum, pleura, and peritoneum have a historical mortality rate of over 50% in most series.^1,3,5,7–10 More recent series quote a mortality rate of 20% to 25% resulting from improved surgical critical care and operative technique.^1,3,5,7–9

Initial management of esophageal perforation involves resuscitation of the patient. The regimen includes administration of intravenous fluids, proton pump inhibitors to reduce gastric acid secretion, broad-spectrum antibiotics to cover oral and gastrointestinal flora (including fungal organisms), and restriction of oral intake. Nasogastric tube placement is avoided initially to prevent worsening the injury, especially if an operative intervention is anticipated. If conservative measures are to be used, a nasogastric tube is carefully placed for gastric decompression.

Surgical treatment for esophageal perforation is the mainstay of therapy; however, nonoperative treatment can be substituted in some situations. Historically, nonoperative management alone with antibiotics and parental hyperalimentation carries a 20% to 40% mortality.^1,3,5,7–13 In selected patients who have well-contained or internally drained perforations and are without septic physiology, nonoperative management may be attempted, especially in those who are poor operative candidates. Many cervical esophageal leaks can be managed this way. However, most thoracic and abdominal leaks require an operative intervention.