Perforation
spontaneous perforations (15%), ingested
Karryll A. Bermillo-BSN3B
Introduction
Esophageal perforation is an
emergency
surgical condition related with high
morbidity and
mortality.
Esophageal perforation is an
emergency
surgical condition related with high
morbidity and
mortality.
Esophageal perforation is an
emergency
surgical condition related with high
morbidity and
mortality.
Esophageal perforation is an
emergency surgical condition related with
high morbidity and mortality.
Esophageal perforation is a full-thickness
injury to the esophagus that can occur
during a number of situations, with the vast
majority of injuries secondary to iatrogenic
causes. However, other causes include
spontaneous perforation, blunt or
penetrating trauma, tumor rupture, injury
from ingested foreign bodies, infection, and
caustic injuries. Prior to the middle of the
last century, esophageal perforation was a
uniformly fatal entity. Advances in
diagnosis, surgical therapy, antimicrobials,
and intensive care now allow survival in the
majority of cases diagnosed and treated in a
timely manner.
Etiology
In a collective review of 559
patients, iatrogenic injury produced 59% of
the esophageal injuries, followed by
foreign bodies (12%), trauma (9%),
operative injury (2%), and tumor perforation
(1%).The incidence of injury during flexible
endoscopy is estimated at 0.03%. This risk
is elevated slightly with the addition of
bougienage and balloon dilatation. Other
infrequent sources include thermal injury
during therapy for gastrointestinal bleeding,
injury during sclerotherapy or ligation of
esophageal varices, and perforation during
photodynamic therapy or stent placement
during the palliation of malignancy.
Risk Factors
 Malignant stricture
 Severe esophagus
 Prior radiation therapy
 History of caustic ingestion
 Eosinophilic esophagitis
 Complex or long strictures
 Presence of esophageal diverticula
 Inexperienced operator
 A large hernia
 Use of high inflation pressures with
balloon dilation
 A history of previous esophageal
perforation
 A history of prior esophageal surgery
Pathophysiology
 Leakage of esophageal and gastric
contents into the mediastinum
 Mediastinum can become
contaminated
 Chemical burn and super infection
 Severe vomiting/severe intrathoracic
pressure
  Rupture of all layers of the
esophageal wall
Clinical Manifestations
Esophageal perforation can present in many
different ways depending on the extent,
mechanism, and location of the perforation,
and can present with vague and nonspecific
symptoms.
Common symptoms include:
 Chest pain
 Dysphagia
 Dyspnea
 subcutaneous emphysema
 Epigastric pain,
 Fever
 Tachycardia and tachypnea.
The pathognomonic, eponymous signs such
as Hammon’s sign (systolic crunching sound
heard on auscultation) and Mackler’s triad
(subcutaneous emphysema, chest pain and
vomiting) are detected in less than half of
the reported cases.
Nursing Diagnosis
 Risk for Imbalance Nutrition
 Risk for Aspiration
Diagnostic Test
Imaging test:
 X-ray
 Fluoroscopy by either a barium
swallow or esophagram
A barium swallow is a test that
shows the inside of your food pipe
(oesophagus). Doctors can use it to
help diagnose esophageal cancer.
You drink white barium liquid,
which shows up on x-rays
 Chest CT scan may be used to
identify the site and scope of the
injury
Medical/ Pharmacological Management
 Have patient remain NPO
 Administer IV fluid
 Antifungal Management
 Broad Spectrum Antibiotics
- Ampicillin-sulbactan
- Piperacillin-Tazobactan
- Carbapenem
Surgical Management
Operative management is required for most
patients to minimize morbidity and
mortality.
 Patients diagnosed early (less than
24 hours after the perforation) can be
treated with debridement of all
devitalized contaminated tissue
followed by primary repair. In
addition, the primary repair should
be enhanced with the use of a
vascularized pedicle flap using
serratus anterior, latissimus dorsi, or
the diaphragm.
 Patients who present by extensive
leakage of fluid, substantial tissue
necrosis, or devitalization or by
major fluid collections should
undergo emergent surgical stenting,
debridement, or drainage to restore
the integrity of the esophagus.
  In rare situations, diversion
procedures or resection of the
esophagus with proximal
esophagostomy and feeding
gastrostomy/jejunostomy can be a
valid option in patients with
extensive contamination who are not
candidates for primary repair due to
friability of the surrounding tissue or
pre-existing esophageal disease
(inoperable malignancy).
 Postoperative healing can be
enhanced by placing a feeding
jejunostomy or gastrostomy tube to
abstain from oral feeding for more
prolonged periods of time and ensure
maximum healing conditions for the
esophagus, especially when
substantial extraluminal leakage
exists. However, this operation is
optional and relies on the surgeon's
preference.
 Oral feedings should be restored
when the patient is stable, with a
contrast esophagram study
confirming the integrity of the
esophagus and the absence of any
leakage.
Nursing Management
Risk for Imbalanced Nutrition
Nursing Interventions:
1. Ascertain etiological factors for decreased
nutritional intake.
Rationale: Several factors may affect a
patient's nutritional intake so it is vital to
assess properly.
2. Assess the patient's ability to obtain and
use essential nutrients. Rationale: Several
factors may affect the patient's nutritional
intake, so it is necessary to assess
accurately.
3. Promote proper positioning. Rationale:
Elevating the head of bed 30 degrees aids in
swallowing and reduces the risk for
aspiration with eating. 4. Offer liquid energy
supplements. Rationale: Energy
supplementation has been shown to produce
weight gain.
5. Consider the possible need for enteral or
parenteral nutritional support w/ the pt,
family, and caregiver, as appropriate.
Rationale: Nutritional support may be
recommended for pt's who are unable to
maintain nutritional intake by oral route.
Risk for Aspiration
1. Assess the level of consciousness &
airway patency.
Rationale: Maintaining an open & clear
airway is vital to retain airway clearance &
reduce the risk for aspiration
2. Assess the patient's ability to cough &
swallow.
Rationale: To assess for any difficulty to
clear airway or any reduced ability to
swallow.
3. Elevate the head of the bed at least 30
degree when tube feeding the pt.
Rationale: To prevent food or liquid to
regurgitate digestive tract & being aspirated
into the air lungs.
4. Assess tube placement before feeding the
patient.
5. Follow the SALT team's advice on the
appropriate Diet of the patient as well as the
proper thickness of the drinks.
Rationale: To prevent food or liquid to be
aspirated into the airways & lungs.

Health Education
1.) Remind patient that he/she is on
NPO diet.
2.) Explain the procedure to the patient
to reduce fear and enhance
cooperation as pre-operative
readiness and post-operative
readiness.
3.) Educate patient to verbalize any
changes he/she notice on the
Nasogastric Tube or on feeding
jejustonomy if present.
Prognosis
The mortality associated with esophageal
perforations depends on the location of the
injury and the interval between perforation
and treatment. Outlook is good if found
within 24 hours of occurring. Most patient
survive if surgery is done <24 hours.