Esophageal Rupture - Causes, Symptoms, Diagnosis, Complications, and Treatment

Introduction:

The esophagus is the tube that serves to pass food from the mouth to the stomach. It is flat in the upper and middle portions and rounded in the lower section. The esophagus lacks a serosal layer, which makes it more vulnerable to perforation or rupture. The most common cause of esophageal rupture is instrumentation for diagnostic and therapeutic reasons. It is estimated to be the cause of 65 percent of all esophageal ruptures. Other causes include trauma, foreign body, and medical conditions like peptic ulcers and disease of the esophagus. Esophageal rupture affects three out of 100000 patients in the United States.

What Is Esophageal Rupture?

An esophageal rupture is a tear or a hole in the esophagus, majorly caused by iatrogenic reasons. Spontaneous rupture may also occur related to vomiting, retching, or swallowing a large food item. It is usually seen in patients who have untreated eosinophilic esophagitis (an immune-mediated condition in which white blood cells build up in the esophagus, causing inflammation).

What Are the Signs and Symptoms of Esophageal Rupture?

The typical signs and symptoms of esophageal rupture include:

• Mild to severe chest pain.

• Fever.

• Nausea.

• Chills.

• Vomiting.

• Pain during swallowing.

• Neck pain or stiffness and air bubbles underneath the skin if the rupture is in the upper section of the esophagus.

• Low blood pressure.

• Hematemesis (blood in vomiting).

• Difficulty breathing.

• Rapid heart rate.

• Melena (dark or black stools).

Atypical symptoms of esophageal rupture include:

• Facial swelling.

• Shoulder pain.

• Difficulty making sounds when trying to speak or an abnormal voice.

What Is the Cause of Esophageal Rupture?

The majority of the cases of esophageal rupture are caused by medical instrumentation for diagnostic purposes and treatment of conditions like esophageal cancer, esophageal peptic stricture, or achalasia (esophageal disorder wherein the food and liquids do not move down the esophagus).

Other causes of esophageal rupture include:

• Violent vomiting (Boerhaave syndrome).

• Severe injury or trauma to the esophagus.

• Cancer of the esophagus.

• Gastric reflux with ulceration.

• Previous surgery of the esophagus.

• Swallowing a foreign object or caustic chemicals like battery acid, and household cleaner.

How to Diagnose Esophageal Rupture?

The diagnosis of the esophageal rupture depends on the patient’s detailed history, physical examinations, signs and symptoms, and diagnostic tests. The test includes:

• Blood Test - It includes a complete blood count and pH test, which are done to establish baseline values and help in follow-up care. Leukocytosis (increased white blood cell count) on complete blood count test is suggestive of almost all esophageal perforation. A pH lower than 7.2 is also suggestive of an esophageal tear, with its contents penetrating the pleural cavity.

• Chest X-ray - This is done to look for air in the soft tissues of the chest and fluid that has leaked from the esophagus into the surrounding areas.

• Contrast Esophagography - Also known as water-soluble contrast barium esophagography. It is performed after a plain chest X-ray to determine the extent and location of the rupture.

• Computed Tomography (CT) - When contrast esophagography is nondiagnostic, cannot be performed, or cannot localize the rupture, a CT scan is performed.

What Are the Complications of Esophageal Rupture?

The complications of esophageal rupture:

• Mediastinitis - Due to a hole in the esophagus, the contents from the esophagus pass into the surrounding areas of the chest, called the mediastinum. This usually results in infection of the mediastinum known as mediastinitis.

• Stricture Formation - Permanent damage to the esophagus causing narrowing.

• Intrathoracic Abscess - It is the circumscribed collection of pus within the lungs. This condition is characterized by the collection of pus, inflammation, and destruction of tissue. Abscess formation can also be seen in and around the esophagus.

• Sepsis - Sepsis occurs due to bacterial invasion in the bloodstream. The degree of mediastinal contamination and the location of esophageal rupture determines the extent of sepsis.

• Respiratory Failure - It is a serious condition in which the person finds it difficult to breathe on their own. The lungs do not get enough oxygen or have too much carbon dioxide.

• Shock - If the esophageal rupture is left untreated, it can progress to shock or even death.

What Are the Treatment Options for Esophageal Rupture?

On suspecting the esophageal rupture, nothing should be given by mouth, and antibiotics should be started immediately. The treatment aims to repair or cover the hole in the esophagus to prevent the leakage of saliva and drainage of the fluid around the esophagus. The treatment options depend on the location of the rupture, the time of diagnosis, its underlying cause, the severity of the infection, and the patient's overall state of health. The treatment options include:

• Fluids are given intravenously (IV).

• Antibiotics are also given intravenously (IV) to treat and prevent infections.

• The fluids around the lungs are drained using a chest tube.

• Mediastinoscopy can be performed to remove the fluids that got collected in the area between the lungs (mediastinum) and the area behind the breastbone.

• Esophageal stenting is used for the treatment of patients with esophageal rupture is increasing nowadays. The stent is placed on the site of rupture for six to eight weeks and subsequently removed. This procedure is done in combination with the drainage of fluids around the esophagus. This is done to avoid surgery.

• A rupture in the upper part of the esophagus may heal itself if the patient does not eat or drink for some time. In such cases, stomach feeding or other ways to get nutrients are recommended.

• Surgical repair is required to repair the rupture, covering the rupture with healthy muscle and drainage of the fluids around the esophagus.

Is Esophageal Rupture life-threatening?

Early diagnosis and treatment save the life. Surgery should be done as soon as possible. Esophageal rupture when left untreated leads to shock or death as it is a direct life-threatening condition.

Conclusion:

Esophageal rupture is a tear in the esophagus. This condition can be life-threatening and can progress to shock or death if left untreated. The prognosis is good if the condition is diagnosed early. Most people show good results if operated within 24 hours. The survival rate of the patients with this condition decreases if the wait is longer. Early diagnosis and timely treatment are the only way out as these conditions are hard to prevent.