What are the other Names for this Condition? (Also known as/Symptoms)

• Esophageal Rupture
• Esophageal Tear
• Perforated Esophagus

What is Esophageal Perforation? (Definition/Background Information)

• Esophageal Perforation is defined as having a hole or rupture in the esophagus. It is an uncommon, but emergency medical condition. The esophagus is a tube that connects the mouth to the stomach
• It forms a part of the upper gastrointestinal tract and is also known as the ‘food-pipe’. The esophagus is subdivided into three parts and spans the neck (cervical), chest (thoracic), and abdominal region; a perforation can occur anywhere in the esophagus
• Some of the causes of Esophageal Perforation include ingesting sharp or toxic materials, swallowing corrosive chemicals, or having certain medical conditions such as gastric reflux
• Individuals, who undergo certain surgical procedures that involve the esophageal region, are at a higher risk for Esophageal Perforation. This is the most common cause of an Esophageal Rupture
• The common signs and symptoms of Esophageal Perforation include severe pain in the region, blood in vomit, and difficulty in breathing and swallowing. The condition may be diagnosed using a chest X-ray or CT scan analysis
• Esophageal Perforation is a life-threatening condition that requires prompt surgical repair. Additionally, the patient may need supportive therapies including intravenous fluids and antibiotics
• A rapid detection and treatment of Esophageal Perforation is crucial for survival; any delays can result in high morbidities and mortalities. It is also important to prevent widespread infection through early treatment
• Generally, if Esophageal Perforation is not detected or treated within 24 hours of onset, the outcome is poor. However, if treatment (surgery to repair the rupture) is initiated before 24 hours, the outcome is improved

Who gets Esophageal Perforation? (Age and Sex Distribution)

• Individuals of any age and gender are prone to Esophageal Perforation. Some reports indicate that there is a higher incidence of the condition in men over 60 years
• Depending on the underlying cause of the condition, some cases are more commonly reported among certain age groups
• The condition is seen worldwide among all racial and ethnic groups

What are the Risk Factors for Esophageal Perforation? (Predisposing Factors)

The risk factors for Esophageal Perforation may include the following:

• The greatest risk factors for Esophageal Perforation are diagnostic or surgical procedures involving the esophagus
• Medical conditions involving the gastrointestinal tract including gastroesophageal reflux disease, Barrett’s esophagus, and certain esophageal or throat cancers/tumors
• Regularly eating a diet consisting of the following foods has a potential to cause acid reflux, which increases one’s risk for Esophageal Perforation:
  • Spicy foods
  • Fatty foods
  • Caffeine products
  • Citrus-based products
  • Drinking alcohol
• Longstanding intake of certain medications taken for unrelated health conditions
• Injury to the neck, chest, upper abdomen, or back
• Consuming corrosive substances and chemicals
• Fishbones or other bones getting stuck in the throat while eating

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Esophageal Perforation? (Etiology)

Esophageal Perforation can be caused by a variety of factors including medical conditions, foreign body ingestion, and external trauma to the chest or back region that result in esophageal injuries.

Iatrogenic Esophageal Perforation (caused while performing certain medical procedures):

• It is the most common cause; about 56% of the cases arise from this factor. Most cases involve the cervical region of the esophagus
• A damage to the esophagus causing it to rupture or tear takes place during diagnostic or treatment procedures involving pointed or sharp medical instruments
• Such medical procedures may include endoscopies or surgeries to the region (for example esophagectomy)

Spontaneous Esophageal Perforation (caused by the following conditions):

• An Esophageal Perforation can be caused by the spontaneous rupturing of the esophagus in a condition known as Boerhaave’s syndrome. The rupture is caused by a high differential pressure between the intraesophagus and intrathoracic region. Around 10% of the cases are attributed to this syndrome
• Benign and malignant throat/esophageal tumors 
• Infectious ulcers caused by gastric reflux (due to GERD); ulcers in AIDS patients
• Pill-induced esophagitis - injury to the mucosal surface of the esophagus causing it to tear/rupture due to harmful effects of certain medications
• Barrett’s esophagus: A condition that results in the transformation of the esophageal lining
• Eating disorder, such as bulimia

Other factors that may result in Esophageal Perforation include:

• Excessive intake of food and alcohol
• Direct injury to the neck or chest region; stabbing/gunshot wounds or blunt trauma
• Accidentally or intentionally swallowing toxic or corrosive substances such as batteries, cleaning fluids, caustic liquids, or other acids
• Accidentally swallowing fish or other bones that get stuck in the throat or food-pipe
• Severe and violent vomiting; profuse vomiting

What are the Signs and Symptoms of Esophageal Perforation?

The signs and symptoms of Esophageal Perforation may include:

• The most common sign is pain in the lower or mid chest region; the pain may radiate to the shoulder
  • Pain is observed in nearly 70% of the individuals
  • Cervical perforations may result in neck pain
  • Epigastric pain may be noted when the abdominal part of esophagus is affected
• Individuals may have trouble swallowing or pain while swallowing; this is seen in nearly 25% of the cases
• Fever; it is seen in 50% of the cases
• Severe retching and vomiting; blood in vomit
• Breathing issues; rapid breathing
• Air gets trapped beneath the skin (subcutaneous emphysema)
• Mackler's triad: It is seen in 1 in 7 individuals and consists of chest pain, vomiting, and subcutaneous emphysema

The signs and symptoms, if any, of the underlying condition may be noted.

How is Esophageal Perforation Diagnosed?

If not evidently identified, it is important to diagnose the underlying condition that resulted in Esophageal Perforation. A diagnosis may involve the following tests and exams:

• Along with a detailed medical history, the healthcare provider may undertake a physical examination and look for several signs that include: 
  • Fever
  • Fast breathing
  • Low blood pressure
  • Fast heart rate
  • Neck pain or stiffness
  • Hamman's sign: It is a chest rasping sound that may be heard by the physician on using a stethoscope
• A chest X-ray can be performed to look for:
  • Air in the soft tissues of the chest and under the skin
  • Collapsed lung
  • Fluid leakage from esophagus to the space around the lungs
• Fluoroscopy: A real-time imaging procedure to study the affected region using X-rays
• CT scan of the chest

A variety of conditions are known to exhibit similar signs and symptoms. Hence, a differential diagnosis to eliminate other conditions or infections may be considered, before arriving at a definitive diagnosis. These include:

• Acute cholecystitis or inflammation of the gallbladder
• Acute coronary syndrome; a condition that causes a sudden disruption of blood supply to the heart
• Aortic dissection; an emergency medical condition caused by a rupture in the aortic wall
• Esophagitis or inflammation of the esophagus, due to a variety of factors
• Gastritis or inflammation of the stomach
• Myocardial infarction, or a heart attack
• Pancreatitis or inflammation of the pancreas
• Peptic ulcer disease; an ulcer that typically develops on the stomach walls
• Pericarditis or inflammation of the pericardial membranes
• Pulmonary abscess; the formation of fluid-filled cavities in the lung, typically from an infection
• Pulmonary embolism; blockage of the pulmonary artery due to a blood clot
• Spontaneous pneumothorax; a collapsed lung that occurs spontaneously in the absence of a known cause

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Esophageal Perforation?

The complications of Esophageal Perforation may vary depending on the underlying cause of the condition. The potential complications include:

• Abscess formation
• Esophageal stricture that may be irreversible
• Severe breathing issues
• Infection in or around the lungs because of fluid getting trapped in the pleural space/lungs, or chest (mediastinal) cavity; pleural effusion
• Collapsed lung or pneumothorax
• Peritonitis, or inflammation of the peritoneum from infection in the region
• Permanent damage to the esophagus
• Sepsis
• Shock, including shallow breathing (tachypnea), abnormal heart rhythms (tachycardia), and low blood pressure may be observed

Complications may occur from diagnostic and therapeutic procedures too such as:

• Use of barium study: The swallowed chemical may spill into the mediastinum resulting in fibrosis and other medical issues
• An endoscopy can cause more air accumulation in the chest cavity or lungs via the perforations, and is hence avoided

Since this condition can be fatal, and in order to prevent any longstanding complications, a suitable treatment should be immediately initiated.

How is Esophageal Perforation Treated?

An emergency medical treatment of Esophageal Perforation is often necessitated, since the condition is potentially fatal or can result in longstanding complications. A treatment of the underlying causative condition is also important.

The treatment measures for a Perforated Esophagus may include:

• Surgery is usually performed to repair the rupture in the esophagus
• In some cases, a stent is placed in the esophagus  
• Intravenously delivered antibiotics are administered to treat infections
• A feeding tube may be necessary to deliver food and nutrients; oral intake of food and fluids is disallowed until healing is achieved
• Mediastinoscopy: It may be performed to remove the fluid between the lungs

In some cases, a rupture in the neck region of the esophagus may heal on its own, provided there is no intake of food and drinks orally for a certain period of time.

How can Esophageal Perforation be Prevented?

In many cases, Esophageal Perforation is difficult to prevent, since it is caused mostly by traumatic events/injuries or during surgical procedures to the region. However, the following factors may be considered:

• Undertaking prompt treatment of any associated/underlying conditions involving the food-pipe such as tumors and cancers, infections, gastric reflux, eating disorders, and Barrett’s esophagus
• Inadvertent swallowing of toxic chemicals may be avoided by properly labelling them and keeping them out of reach of children
• Closely monitor children playing with small sharp/pointed objects
• Chronic consumption of foods that cause heartburn or acid reflux should be avoided to limit damage to the esophagus
• Avoid excessive intake of food and alcohol
• Individuals, with a suppressed or weakened immune system, should limit their exposure to other individuals who are sick
• Medications: While swallowing medications, it is important to drink plenty of water. Also, ensure that drugs are taken standing up. Medications should also not be taken 15-30 minutes before going to bed

Esophageal injury or tear during a medical procedure is rare nowadays, due to the advances in safe medical technologies and practices.

What is the Prognosis of Esophageal Perforation? (Outcomes/Resolutions)

• The prognosis of Esophageal Perforation is based on a variety of factors that include:
  • Location of the perforation within the esophagus
  • Severity of the condition, including the presenting signs and symptoms
  • Promptness of diagnosis and treatment
  • Age of the individual
  • Underlying cause of the rupture
• Untreated Esophageal Perforations can result in severe shock and infections; the condition can become septic and lead to death
• Iatrogenic causes are often easier to treat; less complications are also noted from medical procedures to the region; since the spillage of gastric contents outside the esophagus is not generally observed
• Esophageal Rupture in the cervical region has better overall prognosis than ruptures involving the thoracic or abdominal region
• If Esophageal Perforation is timely detected and medical intervention facilitated within 24 hours of onset, the chances of survival are high. The survival rate significantly decreases after 24 hours, especially with delayed diagnosis and/or commencement of treatment

Nevertheless, according to studies, the risk of fatalities is as high as 25% even with surgery to address the condition.

Additional and Relevant Useful Information for Esophageal Perforation:

The following article link is a helpful resource for other Digestive Health conditions:

https://www.dovemed.com/healthy-living/digestive-center/