Esophageal Perforation

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Chapter 317 Esophageal Perforation

The majority of esophageal perforations in children either are from blunt trauma (automobile injury, gunshot wounds, child abuse) or are iatrogenic. Cardiac massage, the Heimlich maneuver, nasogastric tube placement, traumatic laryngoscopy or endotracheal intubation, excessively vigorous postpartum suctioning of the airway during neonatal resuscitation, difficult upper endoscopy, sclerotherapy of esophageal varices, esophageal compression by a cuffed endotracheal tube, and pneumatic dilatation for therapy of achalasia have all been implicated. Esophageal rupture has followed forceful vomiting in patients with anorexia and has followed esophageal injury due to caustic ingestion, foreign body ingestion, food impactions, pill esophagitis, or eosinophilic esophagitis.

Spontaneous esophageal rupture (Boerhaave syndrome) is less common and is associated with sudden increases in intraesophageal pressure wrought by situations such as vomiting, coughing, or straining at stool. In older children, as in adults, the tear occurs on the distal left lateral esophageal wall, because the smooth muscle layer here is weakest; in neonates (neonatal Boerhaave syndrome), spontaneous rupture is on the right.

Symptoms of esophageal perforation include pain, neck tenderness, dysphagia, subcutaneous crepitus, fever, and tachycardia; several patients with cervical perforations have displayed cold water polydipsia in an attempt to soothe pain in the throat. Perforations in the proximal thoracic esophagus tend to create signs (pneumothorax, effusions) in the left chest, whereas the signs of distal tears are more often on the right. Cervical spine and chest radiographs are often diagnostic, showing mediastinal widening or paracervical free air. If these x-rays are normal, an esophagogram using water-soluble contrast media should be performed, but esophagograms miss >30% of cervical perforations. Therefore, a negative water-soluble contrast esophagogram should be followed by a barium study; the greater density of barium can better demonstrate a small defect, though with a higher risk of inflammatory mediastinitis. Endoscopy may also be useful but carries a 30% false-negative rate. CT of the chest can assist in difficult cases.

Treatment must be individualized. Although small tears and minimal mediastinal contamination can be treated conservatively with broad-spectrum antibiotics, nothing given orally, gastric drainage, and parenteral nutrition, the majority of pediatric esophageal perforations require surgical management.

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Chapter 317 Esophageal Perforation

The majority of esophageal perforations in children either are from blunt trauma (automobile injury, gunshot wounds, child abuse) or are iatrogenic. Cardiac massage, the Heimlich maneuver, nasogastric tube placement, traumatic laryngoscopy or endotracheal intubation, excessively vigorous postpartum suctioning of the airway during neonatal resuscitation, difficult upper endoscopy, sclerotherapy of esophageal varices, esophageal compression by a cuffed endotracheal tube, and pneumatic dilatation for therapy of achalasia have all been implicated. Esophageal rupture has followed forceful vomiting in patients with anorexia and has followed esophageal injury due to caustic ingestion, foreign body ingestion, food impactions, pill esophagitis, or eosinophilic esophagitis.

Spontaneous esophageal rupture (Boerhaave syndrome)

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