Makindo Medical Notes

Related Subjects: |Assessing Chest Pain |Achalasia |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus

Mackler's triad (vomiting, chest pain, and subcutaneous emphysema) is a classical sign of oesophageal perforation but is absent in almost half of the cases. While a chest X-ray (CXR) may reveal surgical emphysema, pneumomediastinum, or pleural effusion, a gastrografin swallow study is often diagnostic. If a gastrografin swallow is not possible or yields negative results, a CT scan should be performed as it can provide more detailed imaging of the perforation.

Oesophageal Perforation

About Oesophageal Perforation

• Oesophageal Perforation: Rupture or tear in the oesophagus that can lead to life-threatening complications such as mediastinitis and surgical emphysema.
• Perforation allows gastric contents to escape into the mediastinum and surrounding structures, which can cause severe infection and inflammation.
• Prompt diagnosis and treatment: Early recognition and intervention are critical to reducing morbidity and mortality.

Aetiology (Causes)

• Endoscopic procedures: Iatrogenic perforation during procedures such as stricture dilatation is the most common cause.
• Boerhaave's syndrome: Spontaneous rupture of the oesophagus following forceful vomiting. This usually occurs on the left posterolateral wall of the lower third of the oesophagus.
• Trauma and malignancy: Perforations can also result from trauma, ingestion of sharp or corrosive objects, or malignant tumours eroding the oesophageal wall.

Clinical Presentation

• Fever, malaise, and vomiting: Common presenting symptoms, often following forceful vomiting or an invasive procedure.
• Chest or back pain: Severe pain, often exacerbated by swallowing, is typical. Pain can radiate to the back.
• Surgical emphysema: Subcutaneous emphysema (air trapped under the skin) may be evident, particularly around the neck and chest. This is often associated with a "crackling" sensation (crepitus) on palpation or auscultation.
• Crackling heart sounds (Hamman’s sign): A crunching or crackling sound heard over the heart due to pneumomediastinum, especially during systole.

Investigations

• Chest X-ray (CXR): May show pneumomediastinum (air in the mediastinum), pleural effusion (often left-sided), or pneumothorax. In cases of pleural effusion, analysis may show low pH, high amylase levels, and the presence of food particles.
• Gastrografin swallow study: A water-soluble contrast study can confirm the diagnosis by showing extravasation of contrast at the site of perforation. However, it may occasionally be falsely negative.
• CT scan: Contrast-enhanced CT of the chest is useful for identifying air or fluid collections in the mediastinum, pneumothorax, and the extent of the perforation. It is highly sensitive and should be used if gastrografin is not diagnostic or contraindicated.
• OGD (Oesophagogastroduodenoscopy): Should be avoided unless done with expert advice, as insufflation of air during the procedure can worsen the tear and increase leakage.

Complications

• Mediastinitis: Infection of the mediastinum caused by leakage of gastric contents, leading to severe inflammation and abscess formation.
• Surgical emphysema: Air trapped in the subcutaneous tissues of the chest or neck.
• Pleural effusion/empyema: Accumulation of fluid or pus in the pleural space, potentially causing respiratory distress.
• Multiorgan failure: Resulting from sepsis due to untreated infection.
• Septic shock and death: If untreated, oesophageal perforation has a high mortality rate.

Management

• Intensive Care Unit (ICU): Most patients require ICU admission with access to cardiothoracic surgeons for early surgical assessment.
• ABC management: Secure airway, establish IV access, and start fluid resuscitation. Provide supplemental oxygen as needed. Consider total parenteral nutrition (TPN) if prolonged nil by mouth is expected.
• Broad-spectrum antibiotics: Initiate antibiotics to cover both anaerobes and aerobic gram-negative and gram-positive organisms. Early antibiotic administration is essential to prevent sepsis.
• Nil by mouth (NPO): Avoid oral intake. Expert advice is required before considering nasogastric (NG) tube placement, particularly if vomiting is present.
• Consultation with cardiothoracic surgeons: Early consultation is essential. Conservative management is favored in small or contained perforations, but surgical repair or stenting may be necessary for larger or symptomatic tears.
• Endoscopic intervention: In some cases, endoscopic stenting or clipping may be used to manage the perforation, especially in stable patients with localized leaks.
• Management tailored to the cause: Treatment should be individualized based on the underlying cause, such as malignant perforation or traumatic injury.