Esophageal perforation

causes (transmural)

1. Iatrogenic ie instrumentation
a. Usually contained , adventitia keep mediastinum separate from the esophagus
2. Effort rupture: boerhave syndrome (prolonged retching), trauma
a. Uncontained: adventia is always torn, all the bacteria and fluid are now in the sterile
mediastinum
3. Esophagitis: infectious, pills, caustic

Hamman's sign is characterized by a crunching or crackling sound that is heard with each heartbeat and is
heard on auscultation over the left chest. This sound is called subcutaneous emphysema and is caused by air
escaping from the ruptured esophagus and tracking through the tissues surrounding the heart

Neck/precordial emphysema

1. Diagnosis
a. Chest X ray or CT using water soluble contrast
b. Chest X ray
i. Air and fluid in the mediastinum
1. Pneumomediastinum ie mediastinal emphysema
2. widened
ii. Air and fluid in thorax
1. Pneumothorax, pleural effusion
c. Esophagography with water soluble contrast
i. You’ll see the contrast leaking form the esophagus into surrounding tissue
d. Upper endo NOT used due to side effects
e. Widened mediastinum:
2. Severe chest pain/and or back
a. Why? Esophagus is in the posterior location
3. Pathophysiology
a. Outflow of air into the mediastinal space: Pneumomediastinum, pneumothorax
b. Fluid-> pleural effusion
c. Leading to inflammatory response: tachy
4. Can lead to
a. Mediastinitis, septic shock, death
5. Management
a. Depends on severity.
i. Not severe medical management: PPI and AB
ii. Severe surgery: emergent debridement and repair
b. Conservation NPO

Procedure side effects

1. ECRP: pancreatitis due to instrumentation and dye injection into the pancreatic duct
2. Upper endo: esophageal perforation