Definition

Esophageal rupture, or Boerhaave’s Syndrome, is a spontaneous tear in the esophageal wall. It is considered an emergency condition requiring prompt treatment to prevent death. The mortality rate for this condition is around 20% to 40%. However, patients with esophageal rupture who do not receive prompt treatment, or at least within 48 hours, have a mortality rate of 100%.

Esophageal rupture is rare, occurring in approximately 1 out of 6000 people worldwide. A classic symptom preceding esophageal rupture is frequent and excessive vomiting.

Causes

Esophageal perforation can be caused by medical instrumentation for diagnostic or therapeutic purposes (iatrogenic), such as post-operative trauma, diagnostic endoscopy, pneumatic dilation, hemostasis, stent placement, foreign body extraction, and endoscopic ablation techniques. Iatrogenic ruptures most commonly occur in the hypopharynx or lower esophagus, while spontaneous ruptures tend to occur in the posterior wall of the esophagus.

The most common cause of esophageal rupture is non-iatrogenic perforation, often due to a sudden increase in intra-esophageal pressure combined with negative pressure in the chest cavity. These ruptures typically occur longitudinally and vary in size, ranging from 0.6 cm to 8.9 cm. The left side of the esophagus is more prone to involvement than the right side, with a 90% percentage. 

Traumatic injuries to the esophagus from penetrating injuries or blunt objects are less common. Penetrating injuries, such as gunshot wounds or stab wounds, occur more frequently than blunt injuries.

Risk factor

There are several risk factors for esophageal rupture, including:

• Frequent and excessive vomiting
• Injuries that can directly tear the esophagus
• Esophageal tumors
• Foreign bodies
• Abnormalities in esophageal tissue
• Medical procedures such as Esophagogastroduodenoscopy, which carries a risk of esophageal rupture.

Esophagogastroduodenoscopy is a therapeutic and diagnostic procedure with a risk chance of 0.03%. However, depending on the procedure chosen and if it is combined with other treatments simultaneously, this risk may increase to 25%.

Symptoms

Esophageal rupture can cause the following symptoms:

• Pain at the site of rupture
• Chest pain
• Difficulty swallowing
• Increased heart rate
• Rapid breathing
• Decreased blood pressure
• Fever
• Shivering
• Vomiting, including vomiting blood
• Neck pain and stiffness

These symptoms are related to the shock condition experienced by the patient due to fluid loss from bleeding. Additionally, patients with infection may experience fever and shivering, as open wounds risk microbial contamination, leading to infection in cases of esophageal rupture.

Diagnosis

Esophageal rupture is a rapidly developing condition; doctors diagnose it by identifying tears in the esophagus. Initially, doctors focus on managing the emergency situation to prevent the patient's condition from worsening and potentially leading to death. Following stabilization, doctors conduct medical interviews and physical examinations to determine the underlying cause of the esophageal rupture.

Doctors may perform diagnostic tests depending on the suspected underlying disease or condition if necessary. These tests may include laboratory tests and radiological examinations such as X-rays or CT scans to confirm signs of esophageal rupture. These examinations aim to assess for the presence of air bubbles and signs of abscess (a cavity containing pus) in the chest.

Management

In general, operative intervention in cases of esophageal rupture requires consideration of various factors, including the underlying cause, the location of the tear, and the duration since the onset of symptoms. The sooner the patient is treated, the better the expected outcomes with surgical intervention. Rapid diagnosis (within 24 hours) is often associated with better recovery. Other important considerations include the extent of the laceration and the patient's overall medical condition.

Several recommendations suggest surgery should be considered if:

• The patient is septic with an unstable clinical condition
• Recent post-emetic perforation is present
• Intra-abdominal perforation is identified
• There are no medical contraindications for surgical procedure (such as severe emphysema or severe coronary artery disease)
• Rupture causes leakage outside the mediastinum (chest cavity)
• Malignancy, obstruction, or strictures (narrowing) in the area of the tear are present

Standard medical procedures for patients with esophageal rupture include:

• Placement in the Intensive Care Unit (ICU)
• No oral intake allowed
• Parenteral nutrition support
• Nasogastric suction, continued until signs of improvement in the perforation area are observed
• Administration of broad-spectrum antibiotics to prevent infections from gram-negative and gram-positive anaerobic bacteria
• Administration of narcotic analgesics for pain management

Complications

Esophageal rupture is a life-threatening condition that requires prompt and appropriate treatment. In severe cases, extensive tears can lead to massive bleeding. If bleeding is not promptly treated, the patient may go into shock, which can be deadly if not addressed promptly and properly. Patients may appear pale and weak and may lose consciousness. Open wounds in patients are prone to infection and if left untreated, can lead to sepsis. Additionally, patients are at risk of respiratory failure and other infections such as mediastinitis (inflammation in the chest cavity) and intra-thoracic abscess (accumulation of pus inside the chest)

Prevention

To prevent esophageal rupture, it is crucial to recognize the clinical conditions apparent in the patient and pay attention to classic symptoms that may lead to esophageal rupture, such as frequent and excessive vomiting. To prevent vomiting, avoid foods that can trigger reflux and vomiting. Additionally, after eating, wait approximately 2-3 hours before lying down to avoid triggering the vomiting reflex.

Prevention strategies to avoid complications include:

• Early treatment involves drainage of fluid from the chest.
• Administration of antibiotics to prevent or treat infections.
• Avoid eating or drinking until treatment is complete; antibiotics and fluids will be administered intravenously.
• Provision of nutrition through a feeding tube.

When to see a doctor?

If you suspect you have an esophageal tear, it is crucial to seek immediate medical attention. Patients treated within 24 hours generally have better recovery outcomes than those treated after 24 hours. Go to the Emergency Department if you experience symptoms such as spontaneous esophageal rupture, vomiting blood, or difficulty swallowing or breathing.