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Esophageal Trauma, Emergency Medicine

Basics

Description

- Sites of esophageal narrowing: - Cricopharyngeal muscle (upper esophageal sphincter) - Crossover of left main stem bronchus and aortic arch - Gastroesophageal junction (lower esophageal sphincter) - Areas of disease (cancer, webs, or Schatzki ring)

- Upper 3rd of esophagus is striated muscle: - Middle portion is mixture of striated and smooth. - Distal portion is smooth muscle. - It is a fixed structure, but can become displaced by other organs: - Goiter - Enlarged atria - Mediastinal masses

- Perforation: - Foreign bodies via direct penetration - Pressure necrosis - Chemical necrosis - Radiation necrosis from selective tissue ablation - Instrumentation

- Internal forces or agents: - Caustic ingestions/burns: - Acid pH < 2, alkali pH > 12 accidental or intentional - Alkali (42%): Liquefaction necrosis causing burns, airway edema or compromise, perforation, chronic stricture, and cancer - Acid (32%): Coagulation necrosis, thermal injury, and dehydration causing perforation, ulceration, and infection, more likely to perforate than alkali - Chlorine bleach (26%): Mucosal edema, superficial erythema

- Drugs: - Less common but case series reported - Alendronate, Doxycycline, NSAIDs - Mycophenolate mofetil - May cause esophageal erosion or esophagitis

- Boerhaave syndrome: - Spontaneous esophageal rupture - Full-thickness rupture of distal esophagus - Classically after alcohol or large meals and vomiting

- Foreign bodies - Accounts for 75-80% of swallowed foreign bodies: - Typically in infants ages 18-48 mo - Entrapment usually at upper esophageal sphincter - Perforations - Commonly iatrogenic with NG insertion, stricture dilation, and endotracheal intubation

- Dysphagia: Difficulty swallowing - Odynophagia: Pain with swallowing - Chest pain: Angina like, often pleuritic, severe, and unrelenting - Hoarseness - Dyspnea - Tears or perforations: - Ingestions/foreign bodies: - Drooling or excessive salivation - Choking, gagging, vomiting, stridor, or wheezing - Inability of food or liquid to pass

- CXR for foreign body or perforation: - Pneumomediastinum - Widened mediastinum - Pneumothorax - Pleural effusion

- Fiberoptic nasopharyngoscopy for foreign body removal - Esophagram for foreign bodies or suspected perforation: - 10-25% false-negative rate - Current recommendations for water-soluble contrast (Gastrografin) 1st if perforation likely - Barium may limit visibility for later endoscopy: - More irritating if extravasates into mediastinum

- Endoscopy for suspected perforation, caustic ingestions, and esophageal foreign body removal - Severity of injury in caustic ingestions - 1st degree: Superficial mucosal damage, focal or diffuse, erythema, edema, mucosa sloughs without scar - 2nd degree: Mucosal and submucosal damage, ulcers and vesicles, granulation tissue and scar formation, stricture possible - 3rd degree: Transmural with deep ulcers, black discoloration, and wall perforation

- Cardiovascular: - Myocardial infarction - Aortic dissection - Spontaneous pneumomediastinum

- Foreign bodies/food impaction: - 80% pass, 20% need endoscopy, <1% need surgery - Glucagon may be tried: 1 mg IV and repeated in 20 min. Carbonated beverage in combo may be more effective - Nitroglycerin or nifedipine may be tried. - Diazepam may be of benefit in the upper (striated muscle) esophagus. - GI consultation and endoscopic extraction if not relieved

- Caustic ingestions: - Emesis/lavage contraindicated - Immediate decontamination with milk - Avoid neutralizing agents as they may cause exothermic reaction. - GI consultation for early endoscopy to provide prognostic information - No role for corticosteroids and may be harmful

- Perforation: - Cefoxitin: 1-2 g (peds: 100-160 mg/kg/24 h) IV q6-8h - Gentamicin: 1-1.7 mg/kg (peds: 1.5-2.5 mg/kg/24 h) IV q8h - Steroids not indicated in caustic ingestions

  • Adult esophagus is ~25-30 cm in length in close proximity to mediastinum with access to pleural space.
  • It begins at hypopharynx posterior to larynx at level of cricoid cartilage.
  • On either side of this slit are piriform recesses:May be site for foreign body to lodge
  • Sites of esophageal narrowing:Cricopharyngeal muscle (upper esophageal sphincter)Crossover of left main stem bronchus and aortic archGastroesophageal junction (lower esophageal sphincter)Areas of disease (cancer, webs, or Schatzki ring)
  • Upper 3rd of esophagus is striated muscle:
  • Middle portion is mixture of striated and smooth.
  • Distal portion is smooth muscle.
  • It is a fixed structure, but can become displaced by other organs:GoiterEnlarged atriaMediastinal masses

Etiology

Mechanism

  • External forces or agents (30%):Penetrating: Leading to tears:Stab woundsMissile woundsPerforation:Foreign bodies via direct penetrationPressure necrosisChemical necrosisRadiation necrosis from selective tissue ablationInstrumentationBlunt: Motor vehicle accident
  • Internal forces or agents:Caustic ingestions/burns:Acid pH < 2, alkali pH > 12 accidental or intentionalAlkali (42%): Liquefaction necrosis causing burns, airway edema or compromise, perforation, chronic stricture, and cancerAcid (32%): Coagulation necrosis, thermal injury, and dehydration causing perforation, ulceration, and infection, more likely to perforate than alkaliChlorine bleach (26%): Mucosal edema, superficial erythemaInfections:Viruses (CMV, HPV, and HSV) or fungi in immunocompromised patientsDrugs:Less common but case series reportedAlendronate, Doxycycline, NSAIDsMycophenolate mofetilMay cause esophageal erosion or esophagitisSwallowed agents:Food bolus impaction:Coins, bones, buttons, marbles, pins, button batteriesMost common type is meat.
  • In adults: Prisoners, psychiatric patients, intoxicated patients, or edentulous patients
  • Iatrogenic (55%):Perforation secondary to instrumentation, endoscopy most common causeNasotracheal intubation/nasogastric (NG) tube most common cause in emergency department
  • Increased gastric pressure (15%):Large pressure differences between thorax and intra-abdominal cavity:May lead to lacerations or perforationMallory-Weiss syndrome:Longitudinal tears in distal esophageal mucosa with bleedingBoerhaave syndrome:Spontaneous esophageal ruptureFull-thickness rupture of distal esophagusClassically after alcohol or large meals and vomiting
  • Foreign bodiesAccounts for 75-80% of swallowed foreign bodies:Typically in infants ages 18-48 moEntrapment usually at upper esophageal sphincterPerforationsCommonly iatrogenic with NG insertion, stricture dilation, and endotracheal intubation
  • Caustic ingestionsMore common in children <5 yrButton batteries highly alkaline and need removal if lodged in esophagus within 4-6 hrPackets of single use laundry/dishwasher detergents are prevalent with AAPCC issuing safety warning

Diagnosis

Signs and Symptoms

General

  • Dysphagia: Difficulty swallowing
  • Odynophagia: Pain with swallowing
  • Chest pain: Angina like, often pleuritic, severe, and unrelenting
  • Hoarseness
  • Dyspnea
  • Tears or perforations:
  • Ingestions/foreign bodies:Drooling or excessive salivationChoking, gagging, vomiting, stridor, or wheezingInability of food or liquid to pass
  • Caustic ingestions:Oral painAbdominal painVomitingDrooling

History

  • History of ingestions (type, time, amount)
  • History of protracted vomiting
  • History of inability to swallow after eating, foreign body sensation in throat
  • History of penetrating trauma
  • History of cancer therapy

Physical Exam

  • Tears or perforations:SubQ air at base of neckHamman crunch:Systolic crunching sound secondary to air in mediastinumShockSepticemiaPeritonitis
  • Penetrating trauma:Associated neck, chest, or abdominal injury with trauma:Most commonly tracheaAssociated with penetrating/blunt trauma
  • Caustic ingestions:Airway edema leading to stridorOral burns

Essential Workup

High level of suspicion and early diagnosis are key:

  • Mortality <5% for perforation if repaired within 24 hr; 75% if delayed
  • Early endoscopy for caustic ingestions
  • Chest/lateral neck radiograph

Diagnosis Tests & Interpretation

Lab

  • CBC in cases of GI bleeding
  • TXC for any extensive bleeding/OR candidate
  • Coagulation studies
  • Electrolytes for protracted vomiting or prolonged foreign body retention
  • Arterial blood gas (ABG) for acid ingestions

Imaging

  • CXR for foreign body or perforation:PneumomediastinumWidened mediastinumPneumothoraxPleural effusion
  • Lateral cervical spine films for foreign body or perforation:Retropharyngeal air or fluidCervical emphysema
  • Fiberoptic nasopharyngoscopy for foreign body removal
  • Esophagram for foreign bodies or suspected perforation:10-25% false-negative rateCurrent recommendations for water-soluble contrast (Gastrografin) 1st if perforation likelyBarium may limit visibility for later endoscopy:More irritating if extravasates into mediastinumWater-soluble contrast provides better visibility:Less reaction if extravasates into mediastinumMay cause chemical pneumonitis if aspiratedNonionic contrast may be safest but more expensive
  • Endoscopy for suspected perforation, caustic ingestions, and esophageal foreign body removalSeverity of injury in caustic ingestions1st degree: Superficial mucosal damage, focal or diffuse, erythema, edema, mucosa sloughs without scar2nd degree: Mucosal and submucosal damage, ulcers and vesicles, granulation tissue and scar formation, stricture possible3rd degree: Transmural with deep ulcers, black discoloration, and wall perforation
  • CT scanning with dilute oral contrast may be useful in diagnosis of perforations.

Differential Diagnosis

  • Pulmonary:Tracheal injuryPneumothorax
  • Cardiovascular:Myocardial infarctionAortic dissectionSpontaneous pneumomediastinum
  • Other esophageal emergencies:Peptic strictureEsophageal neoplasmSchatzki ringDiverticulaAchalasiaDiffuse esophageal spasmNutcracker esophagusGastroesophageal refluxEsophagitisesophagitis esp. teracycline

Treatment

Pre-Hospital

  • Chest pain should be presumed cardiac.
  • Airway protection, frequent suctioning
  • Intravenous crystalloid if patient is hypotensive, vomiting, or if hematemesis is present
  • Pain management
  • Avoid neutralizing agents in caustic ingestions as that may worsen injury.
  • Avoid copious amounts of oral fluids in caustic ingestions to prevent emesis.

Initial Stabilization/Therapy

  • Manage airway and resuscitate as needed
  • Intravenous access, monitoring
  • Early intubation for penetrating neck and chest wounds
  • Frequent suctioning of copious secretions
  • Fluid replacement

Ed Treatment/Procedures

  • Foreign bodies/food impaction:80% pass, 20% need endoscopy, <1% need surgeryGlucagon may be tried: 1 mg IV and repeated in 20 min. Carbonated beverage in combo may be more effectiveNitroglycerin or nifedipine may be tried.Diazepam may be of benefit in the upper (striated muscle) esophagus.GI consultation and endoscopic extraction if not relieved
  • Caustic ingestions:Emesis/lavage contraindicatedImmediate decontamination with milkAvoid neutralizing agents as they may cause exothermic reaction.GI consultation for early endoscopy to provide prognostic informationNo role for corticosteroids and may be harmful
  • Tears/perforations:Partial-thickness tears usually heal spontaneously.GI consultation may be needed for diagnosis (endoscopy).Perforation requires surgical consultation for thoracotomy and primary repair; some patients may be managed nonoperatively.Broad-spectrum parenteral antibiotics for perforation
  • Certain swallowed foreign bodies require GI consultation and endoscopic removal:Sharp objects: Fish bones, straight pins, razor blades, pencilCaustic objects: Button batteries
  • Objects may pass on their own:Coins, buttons, marblesOpen safety pins may pass spontaneously if blunt end forward.
  • Consult pediatric GI specialist.

Medication

  • Foreign bodies/food impactions:Glucagon: 1-2 mg (peds: 0.02-0.03 mg/kg) IV; may repeat once in 20 minNitroglycerin: 0.4 mg sublinguallyDiazepam: 5-10 mg (peds: 1-2 mg) IV
  • Perforation:Cefoxitin: 1-2 g (peds: 100-160 mg/kg/24 h) IV q6-8hGentamicin: 1-1.7 mg/kg (peds: 1.5-2.5 mg/kg/24 h) IV q8hSteroids not indicated in caustic ingestions

Follow-Up

Disposition

Admission Criteria

  • Caustic ingestion
  • Sharp foreign bodies
  • Airway compromise
  • Penetrating neck or chest trauma
  • Evidence of sepsis, mediastinitis, or esophageal perforation
  • Significant bleeding
  • Inability to tolerate oral fluids

Discharge Criteria

  • Self-limited bleeding from partial-thickness tear
  • Foreign body or food impaction that has passed lower esophageal sphincter

Pearls and Pitfalls

Factors to predict outcomes in esophageal injuries:

  • Time to diagnosis and definitive therapy: 24 hr decreases mortality by half.
  • Location of injury: Cervical less than thoracic or abdominal
  • Mechanism of injury: Spontaneous perforation has highest mortality 30-40%; iatrogenic 15-20%, and direct trauma 5-10%.

Additional Reading

  • Abbas G, Schuchert MJ, Pettiford BL, et al. Contemporaneous management of esophageal perforation. Surgery. 2009;146(4):749-755.
  • Gander JW, Berdon WE, Cowles RA. Iatrogenic esophageal perforation in children. Pediatr Surg Int. 2009;25(5):395-401.
  • Plott E, Jones D, McDermott D, et al. A state-of-the-art review of esophageal trauma: Where do we stand? Dis Esophagus. 2007;20:279-289.

See Also (Topic, Algorithm, Electronic Media Element)

  • Boerhaave Syndrome
  • Foreign Body, Caustic Ingestion, Esophageal
  • Mallory-Weiss Syndrome

Codes

ICD9

  • 862.22 Injury to esophagus without mention of open wound into cavity
  • 862.32 Injury to esophagus with open wound into cavity
  • 935.1 Foreign body in esophagus
  • 947.2 Burn of esophagus
  • 530.4 Perforation of esophagus

ICD10

  • S27.813A Laceration of esophagus (thoracic part), initial encounter
  • S27.819A Unspecified injury of esophagus (thoracic part), init encntr
  • T18.108A Unsp foreign body in esophagus causing oth injury, init
  • T28.1XXA Burn of esophagus, initial encounter
  • K22.3 Perforation of esophagus
  • S27.812A Contusion of esophagus (thoracic part), initial encounter
  • S27.818A Other injury of esophagus (thoracic part), initial encounter

SNOMED

  • 320934008 Injury of esophagus (disorder)
  • 47609003 foreign body in esophagus (disorder)
  • 307218005 Traumatic perforation of esophagus (disorder)
  • 23509002 Caustic esophageal injury (disorder)
  • 235626005 Rupture of esophagus (disorder)
  • 84621006 Injury of esophagus with open wound into thoracic cavity (disorder)