Chief Complaint:

Esophageal Foreign Body

HPI:

31-year-old male presents to emergency department with reports of an esophageal foreign body. He states that he was eating chicken and had a large piece of chicken get stuck in his chest. He is vomiting up liquid after attempts of swallowing water, not able to get anything down orally. He reports he tried drinking soda without any improvement. This occurred at 5 PM. He has had something similar in the past but it responded to soda and he never had to come to the ED before.

Exam and labs: unremarkable

ED Course:

Patient did not have improvement with Valium or glucagon. GI was attempting to use endoscopy for food bolus removal. There was some concern of possible perforation. Chest x-ray ordered and found no evidence of pneumomediastinum. GI discussed with the ENT physician plan for operating room for further attempts of removal via rigid esophagoscopy.

Hospital Course:

The patient was brought to OR for attempted foreign body extraction with rigid esophagoscopy by ENT, the foreign body could not be removed. Due to the EGD attempt with air insufflation and what was subsequently determined to be a distal esophageal perforation, there was a resulting right pneumothorax. General Surgery was consulted and the patient ultimately underwent placement of a right-sided chest tube as well as a left-sided VATS for removal of the foreign body and repair of the distal esophageal perforation. He was transferred to the ICU postoperatively. He was in the ICU for 3 days intubated with pain control issues. An epidural catheter was placed for pain control and then he was extubated. Nasogastric tube was in place for 5 days and a gastrografin esophogram revealed no leak from the repair site. He was discharged with GI and surgery clinic follow up on day 13 of hospital stay.

Images:

IMPRESSION:
1. Small right pneumothorax on the initial study, increased in size to become a large right pneumothorax with leftward mediastinal shift on the subsequent study (red arrows).
2. Distal esophageal perforation with Gastrografin instilled in the esophagus seen in the right mediastinum outside of the esophageal lumen (blue arrows).

DISCUSSION:

Background:

Esophageal perforation is a rare but potentially life-threatening condition that occurs when there is a full thickness tear of the esophagus which then allows gastric contents to enter the mediastinal cavity. The incidence of esophageal perforation is 3.1 per 1,000,000 per year with the majority occurring secondary to iatrogenic procedures. Boerhaave syndrome, also known as spontaneous esophageal rupture, is less frequently encountered and represents approximately 15% of esophageal rupture cases. In Boerhaave syndrome, spontaneously increased intra-esophageal pressure, usually secondary to forceful vomiting, leads to barogenic esophageal rupture. Alcoholism and excessive food intake are considered two common risk factors for developing Boerhaave syndrome because of their propensity to cause repeated bouts of emesis. Other activities that increase intra-esophageal pressure such as weightlifting, defecation, childbirth, and epileptic seizures have been noted to cause spontaneous esophageal rupture in rare instances. Esophageal perforation is a highly lethal gastrointestinal disorder and therefore prompt recognition and management is necessary to improve mortality outcomes.

Diagnosis:

Emergency providers should suspect esophageal perforation in any patient with severe, recurrent vomiting, excruciating chest pain, and subcutaneous emphysema. This set of symptoms is neither sensitive nor specific but is referred to as Mackler’s triad and is virtually pathognomonic for Boerhaave syndrome in the setting of heavy alcohol intake. In reality, the picture can be more complex as the symptoms of esophageal rupture vary based on the location of the perforation, degree of gastrointestinal leakage, and time between the rupture and presentation. While chest pain is listed as part of Mackler’s triad and is frequently seen in intra-thoracic ruptures, cervical esophageal perforations tend to present with neck pain, dysphagia, and dysphonia. Alternatively, intra-abdominal perforations more often have epigastric pain that radiates to the shoulder or back. Additionally, subcutaneous emphysema is only seen in around 60% of esophageal perforations therefore the absence of subcutaneous emphysema does not preclude the possibility of rupture. Another characteristic but unreliable sign associated with esophageal rupture is Hamman’s sign, which identifies mediastinal emphysema by the presence of mediastinal crackling heard on cardiac auscultation when the patient is lying in the left lateral decubitus position. Although Hamman’s sign is indicative of esophageal perforation, it is seen only in a small portion of patients and is therefore of limited diagnostic utility.

To definitively diagnose an esophageal perforation, emergency physicians should first obtain a chest X-ray. In patients with esophageal perforation, the chest x-ray may demonstrate radiographic abnormalities such as subcutaneous or mediastinal emphysema, mediastinal widening, and/or pleural effusion. These signs are seen in approximately 90% of cases, but are generally nonspecific in nature and can take hours to develop. So while a chest X-ray can help raise suspicion of perforation, additional imaging is required to confirm the diagnosis.

The confirmatory test of choice for esophageal rupture is contrast esophagography using a water-soluble contrast agent such as gastrografin. This may show the extravasation of contrast material at the site of the perforation, which can confirm the diagnosis. If a gastrografin esophagram is negative, a barium esophagram can be performed because it is superior in demonstrating small perforations, however extravasation of barium into the mediastinal and pleural cavities carries with it a risk of mediastinitis and fibrosis. A CT scan of the chest and/or abdomen can also be performed to help diagnose esophageal perforation if it is not easily discovered on contrast esophagography. While CT is highly sensitive for detecting small amounts of extravasated contrast or air in soft tissues around the rupture, it will not definitively identify the site of perforation. The use of endoscopy is controversial and should be avoided if at all possible as there is a high risk of worsening the tear during the procedure. Ultimately, diagnosing spontaneous esophageal perforation is challenging due to its varied presentation and overall rarity. All emergency physicians should keep Boerhaave syndrome on their differential for any patient who has chest, abdominal, or neck pain along with a history of severe vomiting because rapidly diagnosing and repairing a ruptured esophagus significantly improves patient outcomes.

Management in ED:

Severity of patient presentation and characteristics of the esophageal injury will dictate overall management. Initial interventions in the emergency department should include intravenous access, telemetry monitoring, initiation of broad-spectrum antibiotics, and surgical consult. The patient should be kept NPO while in the ED. Laboratory evaluation should include blood typing and crossmatch in preparation for transfusion and surgical management. Other possible requirements are fluid resuscitation, supplemental oxygen, endotracheal intubation, and pain management depending on the clinical scenario. A nasogastric tube may be required for gastrointestinal decompression, but should only be placed at the time of esophagoscopy under direct visualization and in consultation with surgery. All patients with esophageal perforation require emergent surgical consultation. Even patients who will not be surgically managed should be admitted for further observation.

Prognosis:

Prognosis of esophageal perforation is dependent on several variables including mechanism and severity of injury, time to diagnosis, presence of underlying esophageal disease, and management. One multi-institution study found that in penetrating esophageal injuries, the overall mortality was 19%. In this same study, 6% of patients died in the ED from various causes and 8.6% of patients died in the operating room. Later complications, some of which resulted in death, included wound infection, abscess, suture line dehiscence, fistula formation, mediastinitis and empyema. The mortality rate for patients with Boerhaave syndrome as referenced in the literature ranges from 13-40% with rapid diagnosis and treatment being associated with a better prognosis.

Differential Diagnoses:

• • Acute coronary syndrome (ACS)
  • Aortic dissection
  • Cardiac tamponade
  • Coronary artery dissection
  • Esophageal perforation (Boerhhaave’s syndrome)
  • Pulmonary embolism
  • Tension pneumothorax or pneomuthorax
  • Mediastinitis
  • Myocardial rupture
  • Myocarditis/pericarditis
  • Pancreatitis

Clinical Pearls:

• • Esophageal perforation is a full-thickness tear of the esophagus with leakage of gastric contents into the mediastinum.
  • Iatrogenic injury from endoscopic procedures is the number one cause of esophageal perforation. Alcoholism and excessive food intake and common risk factors.
  • Mackler’s triad is neither sensitive nor specific but includes excessive vomiting, excruciating chest pain, and subcutaneous emphysema.
  • Chest x-rays should first be obtained in patients with suspected esophageal perforation. Chest x-rays may reveal widening of the mediastinum, pleural effusions, and subcutaneous or mediastinal emphysema.
  • Gastrografin studies are the test of choice in diagnosing esophageal perforation which may show extravasated contents into the mediastinum.
  • All esophageal rupture patients require emergent surgical consultation. Additionally, the patient should be placed on broad-spectrum antibiotics, IV access, and telemetry.
  • Mortality ranges anywhere from 13-40% with worse prognosis correlating with delays in diagnosis and treatment.

References:

1. Asensio, J. A., Chahwan, S., Forno, W., MacKersie, R., Wall, M., Lake, J., … & Chan, L. (2001). Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 50(2), 289-296.
2. Sarr, M. G., Pemberton, J. H., & Payne, W. S. (1982). Management of instrumental perforations of the esophagus. The Journal of Thoracic and Cardiovascular Surgery, 84(2), 211-218.
3. Ökten, İ., Cangir, A. K., Özdemır, N., Kavukçu, Ş., Akay, H., & Yavuzer, Ş. (2001). Management of esophageal perforation. Surgery today, 31(1), 36-39.
   Mavroudis, C. D., & Kucharczuk, J. C. (2014). Acute management of esophageal perforation. Current Surgery Reports, 2(1), 1-8.
   
4. Sdralis EIK, Petousis S, Rashid F, Lorenzi B, Charalabopoulos A. Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Dis Esophagus. 2017;30(8):1-6.
5. Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome. Thorac Cardiovasc Surg. 2010;58(8):476-480.
6. Kaman L, Iqbal J, Kundil B, Kochhar R. Management of Esophageal Perforation in Adults. Gastroenterology Res. 2010;3(6):235-244.
   
7. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004;77(4):1475-1483.
   

Authors

Jack Spartz, MSIV

Peter Haskins, MSIV

Josh Wahba, MSIV

Kirsten Hughes, MSIII

Mark O’Brien, MSIII