Esophageal perforation

At a Esophageal perforation an injury creates a hole in the esophagus. Often this is the result of a foreign body swallowed. The 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. A submucosal layer of connective tissue lies above it. The third layer is that Tunica musculais.

It uses muscle contractions to transport food from the mouth to the stomach. At a Esophageal perforation all layers of the wall of the esophagus are injured in such a way that a breakthrough occurs. Overall, the disease is rather rare. However, the death rate is 10 to 30 percent.

causes

There are different causes for an esophageal perforation. Most often it arises through the iatrogenic route. Iatrogenic diseases are called if they have been caused by medical measures. Iatrogenic esophageal perforation is usually caused by reflections. 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 a foreign body in the esophagus. A foreign body from the esophagus is a swallowed object that, due to its size, cannot be transported into the stomach, but remains stuck in the esophagus. The most common ingested foreign objects that cause perforation include herringbones, dentures, and peach stones. Children also often swallow small toys or coins.

The majority of the objects get stuck in the first narrow esophagus. 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 foreign bodies in the esophagus, severe reflux diseases can also lead to perforation of the esophagus. In gastro-oesophageal reflux disease, gastric acid refluxes into the esophagus. Reflux disease is also popularly known as heartburn.

The gastric acid damages the lining of the esophagus. Chronic inflammation and, in the worst case, perforation occur. The spontaneous perforation of the esophagus is also known as Boerhaave's syndrome. Here a spontaneous tear develops through all layers of the wall of the esophagus. Usually the syndrome arises as a result of a sharp increase in pressure inside the esophagus. This is mainly the result of excessive vomiting.

Symptoms, ailments & signs

The esophageal perforation manifests itself very differently. In most cases there is pain. The pain usually occurs very suddenly and with great intensity. In addition, there may be vomiting of blood (haemetemesis). If the blood is vomited directly, it is light. If the blood has already had contact with the stomach acid, however, it appears brownish. In this case, one speaks of breaking coffee grounds. Due to the severity of the disease, the circulatory system also reacts.

The pulse accelerates and the loss of blood leads to a drop in blood pressure. Depending on the amount of bleeding, hypovolemic shock can result. Skin emphysema can appear, especially in the case of ruptures in the neck area. Skin emphysema is a build-up of gas in the subcutaneous tissue. It usually arises after the air-containing organs have opened.

If the lower third of the esophagus ruptures, a serothorax or a pneumothorax can occur.A serothorax is when serous fluid accumulates in the chest. 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 middle membrane space (mediastinum) and a widening of the middle membrane space. The skin emphysema and the fluid level in the area of ​​the mediastinum also indicate a perforation.

Contrast media recordings or CT examinations can be used for further diagnosis. Endoscopic causes can also be helpful in making the diagnosis. Under certain circumstances, however, the perforation site can be overlooked during endoscopy due to blood layers.

Complications

The esophageal perforation is an extremely life-threatening medical emergency that requires immediate surgery. It is a breakthrough in the esophagus. Often the esophageal injuries are caused by swallowing sharp objects.

Severe bleeding occurs and, in the worst case, inflammation of the middle skin (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 up to circulatory shock, which can also be fatal. The most dangerous complication of an esophageal perforation is mediastinitis.

This is triggered by the chyme coming from the esophagus into the mediastinal space (middle membrane). This can infect the middle membrane with bacteria. Purulent inflammation occurs, which can lead to chest pain, severe shortness of breath and, in extreme cases, 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 middle skin inflammation. Further complications of an esophageal perforation are skin emphysema and pneumothorax. With skin emphysema, free air gets under the skin. The pneumothorax is characterized by the entry of air into the pleural space. The pneumothorax is also potentially life-threatening if it develops into what is known as a tension pneumothorax.

When should you go to the doctor?

If a foreign body is accidentally swallowed, it must be checked afterwards whether there are any further irregularities. In children in particular, it should be checked whether they are free of symptoms. If there is a full recovery within a few minutes or hours, no further visit to a doctor is usually required. However, if there are impairments, a doctor should be consulted immediately. If pain occurs, blood is vomited or irregularities in the heart rhythm appear, action is required. Changes in speech, problems swallowing or loss of appetite are signs of a health disorder. A doctor should be seen so that a full medical examination can be initiated.

A bloody taste in the mouth, breathing disorders or a refusal to eat should be interpreted as an alarm signal. Medical care is necessary so that further complications can be avoided. If the person looks pale, has a rapid decrease in physical resilience or an internal weakness, the person concerned needs help. A doctor should be seen as internal bleeding may occur. If the lungs can no longer be fully filled without impairment, the observation should be discussed with a doctor. If the complaints increase, it should be checked whether an ambulance service should be alerted. Difficulty breathing or breathing noises must be monitored by a doctor.

Therapy & Treatment

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

Treatment without surgery is only possible in absolutely exceptional cases for very small and uncomplicated tears. After the opening has been surgically closed, regular checks for scarred contractions must be carried out. Reflux diseases and carcinomas must also be ruled out by the doctor at regular intervals.

You can find your medication here

➔ Medicines against vomiting and nausea

prevention

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

This also leads to increased gastric acid reflux. Clothing that is too tight can also encourage reflux. The same applies to mental tension and stress. If a foreign body is swallowed, a doctor should also be consulted as soon as possible. This can remove the foreign body of the esophagus and thus prevent perforation of the esophagus.

You can do that yourself

In everyday life, children in particular should be warned repeatedly not to put foreign objects in their mouths or swallow them. A control by the legal guardian or supervisor is essential. Adults who repeatedly put objects in their mouths, suckle on them or chew on them should try to get rid of this behavior on their own. If you need support or assistance in changing your behavior, you should seek therapeutic help.

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

The intake of food should be checked in everyday life. When eating fish, care should be taken to ensure that it is free of bones. Fruits that contain seeds must be freed from them in advance. In particular, children and adolescents should 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 in processed products such as cakes, seeds or stones appear unintentionally.