Esophageal Perforation

Esophageal Perforation

With an esophageal perforation, an injury creates a hole in the esophagus. This is often the result of swallowing a foreign body. Perforation of the esophagus can lead to inflammation of the mediastinum.

What is an esophageal perforation?

The esophagus is a muscular tube about 25 centimeters long that connects the mouth with the stomach. The esophagus has the same wall structure as the other digestive organs. The innermost layer consists of mucous membrane. Above this is a submucosal layer of connective tissue. The third layer is the tunica musculais. For what is the definition of dna, please visit healthknowing.com.

It uses muscle contractions to transport food from the mouth to the stomach. In the case of an esophageal perforation, all layers of the wall of the esophagus are damaged in such a way that a perforation occurs. The disease is rather rare overall. However, the mortality rate is between 10 and 30 percent.

Causes

There are different causes for an esophageal perforation. It most commonly occurs iatrogenically. Disease patterns are referred to as iatrogenic if they were caused by medical measures. An iatrogenic esophageal perforation is usually caused by endoscopy. In the so-called esophascopy, the esophagus is mirrored with an endoscope. The esophagus can also be injured during a gastroscopy.

The perforation can also be caused by an esophageal foreign body. An esophageal foreign body is a swallowed object that cannot be transported to the stomach due to its size, but gets stuck in the esophagus. The most common ingested foreign objects that cause perforation include fish bones, dentures, and peach stones. Children also often swallow small toys or coins.

The majority of objects get stuck in the first esophageal stenosis. This is located directly behind the cricoid cartilage at the level of the larynx. Here the esophagus has an inner diameter of only about 15 millimeters. In addition to esophageal foreign bodies, severe reflux diseases can also lead to perforation of the esophagus. In gastroesophageal reflux disease, stomach acid backflows up into the esophagus. Reflux disease is also popularly known as heartburn.

The lining of the esophagus is damaged by stomach acid. This leads to chronic inflammation and, in the worst case, to perforation. Spontaneous perforation of the esophagus is also known as Boerhaave’s syndrome. Here, a spontaneous tear develops through all wall layers of the esophagus. The syndrome usually develops as a result of a sharp increase in pressure within the esophagus. This is mainly the result of profuse vomiting.

Symptoms, Ailments & Signs

Esophageal perforation manifests itself in very different ways. In most cases there is pain. The pain usually occurs very suddenly and with high intensity. Blood vomiting ( hememesis ) can also occur. If the blood is vomited up directly, it is light-colored. However, if the blood has already come into contact with stomach acid, it appears brownish. In this case, one speaks of coffee grounds vomit. Due to the severity of the disease, the circulatory system also reacts.

The pulse accelerates and the blood loss causes a drop in blood pressure. Depending on the amount of bleeding, hypovolemic shock may occur. Cutaneous emphysema can occur particularly with ruptures in the neck area. Skin emphysema is gas accumulation in the subcutaneous tissue. It usually occurs after the opening of air-containing organs.

Ruptures in the lower third of the esophagus can lead to a serothorax or a pneumothorax. A serothorax is an accumulation of serous fluid in the chest cavity. In a pneumothorax, there is air in the pleural space. This prevents the affected lung from expanding. Breathing disorders occur.

Diagnosis & course of disease

The majority of esophageal perforations can be diagnosed with a chest x-ray. There is air in the mediastinum and a widening of the mediastinum. Skin emphysema and fluid levels in the mediastinum also indicate perforation.

Contrast images or CT scans can be used for further diagnostics. Endoscopic causes can also be helpful in making the diagnosis. Under certain circumstances, however, the perforation site can be overlooked during endoscopy due to superimposed blood.

Complications

Esophageal perforation is an extremely life-threatening medical emergency that requires immediate surgery. It is a perforation of the esophagus. Esophagus injuries are often caused by swallowing sharp objects.

Severe bleeding occurs and, in the worst case, mediastinitis, which has a high mortality rate even with comprehensive therapy. The heavy bleeding leads to blood vomiting and, in some cases, to a drop in blood pressure and even circulatory shock, which can also be fatal. However, the most dangerous complication of an esophageal perforation is mediastinitis.

This is triggered by the chyme coming from the esophagus into the mediastinal space (membrane). This allows the middle coat to become infected with bacteria. Purulent inflammation occurs, which can lead to chest pain, severe shortness of breath and, in extreme cases, to sepsis. Sepsis is the most serious complication of mediastinitis and thus esophageal perforation.

The mortality rate for an esophageal perforation is between 10 and 30 percent. This high mortality is caused in particular by a median inflammation. Other complications of esophageal perforation are skin emphysema and pneumothorax. In skin emphysema, free air gets under the skin. Pneumothorax is characterized by the entry of air into the pleural space. Pneumothorax is also potentially life-threatening if it develops into a so-called tension pneumothorax.

When should you go to the doctor?

If a foreign body is accidentally swallowed, it must then be checked whether there are any other irregularities. In children in particular, it should be checked whether there are no symptoms. If a full recovery occurs within a few minutes or hours, no further visit to a doctor is usually required. In the case of existing impairments, however, a doctor must be consulted immediately. If pain occurs, blood is vomited or irregularities in the heart rhythm appear, there is a need for action. Changes in speech, problems with swallowing or a loss of appetite are signs of a health problem. A doctor must be consulted so that a comprehensive medical examination can be initiated.

A bloody taste in the mouth, breathing difficulties or a refusal to eat should be interpreted as an alarm signal. Medical care is necessary to prevent further complications. If the person concerned looks pale, has a rapid decrease in their physical resilience, or has an inner weakness, they need help. A doctor should be consulted as internal bleeding may occur. If the lungs can no longer be filled fully without impairment, the observation should be discussed with a doctor. If the number of complaints increases, it should be checked whether an emergency service should be called. Shortness of breath or wheezing must be monitored by a doctor.

Treatment & Therapy

An esophageal perforation usually requires surgical closure of the perforation. Infusions are given to prevent hypovolemia. Prophylactic antibiotics are also administered to protect against bacterial infections. In the case of very severe inflammation of the esophagus, tumors, chemical burns or the so-called megaesophagus, the affected sections of the esophagus are surgically removed.

Treatment without surgery is only possible in exceptional cases with very small and uncomplicated tears. After the surgical closure of the breakthrough, regular checks for scarring contractions must be carried out. Reflux diseases and carcinomas must also be ruled out by the doctor at regular intervals.

Prevention

To prevent esophageal perforation, a doctor should always be consulted if you have heartburn. In particular, people who like to eat large quantities and especially fatty foods are affected by heartburn. In this case, gastric emptying is delayed. The longer stay in the stomach promotes reflux into the esophagus. Acidifiers such as sweets, alcohol and coffee should be avoided if you have a tendency to heartburn. Among other things, they also ensure that the esophageal muscle becomes slacker.

This also leads to an increased reflux of gastric acid. Clothing that is too tight can also promote reflux. The same applies to mental tension and stress. If you swallow a foreign body, you should also see a doctor as soon as possible. This can remove the esophageal foreign body and thus prevent perforation of the esophagus.

You can do that yourself

In everyday life, children in particular should always be warned not to put any foreign objects in their mouths or swallow them. Control by the legal guardians or supervisors is essential. Adults who repeatedly put objects in their mouths, suck on them, or chew them should try to stop this behavior on their own. If they need support or assistance in changing their behavior, they should seek help from a therapist.

Since swallowing foreign bodies can lead to a life-threatening condition, first aid should be given immediately if any irregularities occur. People from the immediate vicinity must call a paramedic and help the person concerned to spit out the foreign body using the first aid measures they have learned. The mortality rate from esophageal perforation is unusually high at nearly 30 percent. For this reason, taking action as quickly as possible is life-saving.

The supply of food must be checked on a daily basis. When eating fish, care should be taken that it is bone-free. Fruit that contains seeds must be freed from them beforehand. Children and adolescents in particular must always be made aware of the dangers of food intake. Reminders are necessary because tips and hints that are often given are forgotten. In addition, it happens again and again that unintentionally appear in processed products such as cakes, seeds or stones.

Esophageal Perforation