Definition

Esophageal perforation is a life-threatening condition. Saliva is spread from the esophagus to surrounding tissues, resulting in infection. If untreated, esophageal perforation can result in sepsis (severe infection) and death.

Causes

The majority of esophageal perforations are caused by instrumentation following an upper endoscopy and dilation of the esophagus for treatment of conditions such as esophageal peptic stricture, achalasia or esophageal cancer. The esophagus can also be perforated following severe vomiting.  

Symptoms

• Chest pain
• Odynophagia (pain on swallowing)
• Fever
• Chills

Diagnosis

Esophageal perforation should be suspected if – following any episode of vomiting or an upper endoscopy – the patient complains of neck or chest pain, rapid heart rate, fever or chills. The following studies can confirm the diagnosis of esophageal perforation. 

Videoesophagram

In cases of esophageal perforation, the esophagram shows leakage of barium outside of the esophagus to the surrounding tissues.

Upper endoscopy

Upper endoscopy can be safely performed following esophageal perforation. It should be performed by expert hands and by the same surgical team that is planning to repair the esophagus. Upper endoscopy allows assessing the underlying esophageal disease, and the exact location and the extent of esophageal perforation.

Computed tomography scan (CT scan)

In cases of esophageal perforation, a CT scan shows, air around the esophagus and leakage of the barium from the esophagus into the surrounding tissues.

Treatment

Nothing should be given by mouth and antibiotics should be started as soon as esophageal perforation is suspected. Treatment requires repair or covering of the hole in the esophagus to prevent leakage of saliva, and drainage of the fluid around the esophagus. The treatment options depend on the time of diagnosis of perforation, location of the perforation, its underlying cause, the patient’s overall state of health and the severity of infection. The treatment options include:

Esophageal stenting

There has been an increase in use of esophageal stents for treatment of patients with esophageal perforation. The stent is placed for six to eight weeks and is subsequently removed.  This procedure should be done in combination with drainage of fluid around the esophagus. 

Surgical treatment

Surgical treatment includes repair of the hole in the esophagus, coverage of the repair with healthy muscle and drainage of the fluid around the esophagus. In cases of esophageal perforation in the neck, open drainage of the fluid around the esophagus will be enough in the majority of cases.

Esophageal perforation in the chest has a higher risk of complications and will require both repair of the hole and drainage of the fluid around the esophagus. In a selected group of patients, esophageal diversion (the esophagus in the neck is brought out and sewn to the skin to divert saliva out of the esophagus to reduce the risk of infection) or esophagectomy may be required.