Basics
Description
- 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 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
Etiology
Mechanism
- External forces or agents (30%):
- Penetrating: Leading to tears:
- Stab wounds
- Missile wounds
- Perforation:
- Foreign bodies via direct penetration
- Pressure necrosis
- Chemical necrosis
- Radiation necrosis from selective tissue ablation
- Instrumentation
- Blunt: Motor vehicle accident
- 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
- Infections:
- Viruses (CMV, HPV, and HSV) or fungi in immunocompromised patients
- Drugs:
- Less common but case series reported
- Alendronate, Doxycycline, NSAIDs
- Mycophenolate mofetil
- May cause esophageal erosion or esophagitis
- Swallowed agents:
- Food bolus impaction:
- Coins, bones, buttons, marbles, pins, button batteries
- Most common type is meat.
- In adults: Prisoners, psychiatric patients, intoxicated patients, or edentulous patients
- Iatrogenic (55%):
- Perforation secondary to instrumentation, endoscopy most common cause
- Nasotracheal 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 perforation
- Mallory-Weiss syndrome:
- Longitudinal tears in distal esophageal mucosa with bleeding
- 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
- Caustic ingestions
- More common in children <5 yr
- Button batteries highly alkaline and need removal if lodged in esophagus within 4-6 hr
- Packets 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 salivation
- Choking, gagging, vomiting, stridor, or wheezing
- Inability of food or liquid to pass
- Caustic ingestions:
- Oral pain
- Abdominal pain
- Vomiting
- Drooling
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 neck
- Hamman crunch:
- Systolic crunching sound secondary to air in mediastinum
- Shock
- Septicemia
- Peritonitis
- Penetrating trauma:
- Associated neck, chest, or abdominal injury with trauma:
- Most commonly trachea
- Associated with penetrating/blunt trauma
- Caustic ingestions:
- Airway edema leading to stridor
- Oral 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:
- Pneumomediastinum
- Widened mediastinum
- Pneumothorax
- Pleural effusion
- Lateral cervical spine films for foreign body or perforation:
- Retropharyngeal air or fluid
- Cervical emphysema
- 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
- Water-soluble contrast provides better visibility:
- Less reaction if extravasates into mediastinum
- May cause chemical pneumonitis if aspirated
- Nonionic contrast may be safest but more expensive
- 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
- CT scanning with dilute oral contrast may be useful in diagnosis of perforations.
Differential Diagnosis
- Pulmonary:
- Tracheal injury
- Pneumothorax
- Cardiovascular:
- Myocardial infarction
- Aortic dissection
- Spontaneous pneumomediastinum
- Other esophageal emergencies:
- Peptic stricture
- Esophageal neoplasm
- Schatzki ring
- Diverticula
- Achalasia
- Diffuse esophageal spasm
- Nutcracker esophagus
- Gastroesophageal reflux
- Esophagitis
- esophagitis 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 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
- 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, pencil
- Caustic objects: Button batteries
- Objects may pass on their own:
- Coins, buttons, marbles
- Open 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 min
- Nitroglycerin: 0.4 mg sublingually
- Diazepam: 5-10 mg (peds: 1-2 mg) IV
- 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
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)