Oesophageal Tears

Question 1

What are oesophageal tears?

Answer 1

Oesophageal tears are ruptures to any part of oesophageal wall.

Question 2

What is the mortality of full thickness rupture of the oesphagus?

Answer 2

Although rare, full ruptures have a mortality of between 50 – 80%, so early recognition and treatment is essential.

Question 3

What are the 2 main subcategories of oesphageal tears?

Answer 3

There is a wide spectrum in the severity of oesophageal tears, the main two subcategories being superficial mucosal tears (Mallory-Weiss tears) and full thickness ruptures.

Question 4

What is an oesphageal perforation?

Answer 4

Oesophageal perforation is a full thickness rupture of the oesophageal wall; if it is spontaneous (often due to vomiting), it is often called Boerhaave’s syndrome.

Question 5

Why is a oesophageal perforation dangerous?

Answer 5

Perforation will result in leakage of stomach contents into the mediastinum and pleural cavity, which triggers a severe inflammatory response which will rapidly become overwhelming, resulting in a physiological collapse, multi-organ failure, and death. Rapid identification and management is therefore essential.

Oesophageal rupture is a surgical emergency and patients deteriorate rapidly, rapid identification and management is therefore essential.

Question 6

What can cause an oesphageal perforation?

Answer 6

The two most common causes are iatrogenic (such as endoscopy) or after severe forceful vomiting.

Question 7

Where is the most common site for oesophageal perforation?

Answer 7

The most common site of perforation is just above the diaphragm in the left postero-lateral position, although it can occur elsewhere in the oesophagus.

Question 8

What are the clinical features of oesphageal perforation?

Answer 8

The classic picture is of a patient who presents with severe sudden-onset retrosternal chest pain, respiratory distress and subcutaneous emphysema following severe vomiting or retching.

Question 9

What investigations should be ordered for oesophageal perforation?

Answer 9

Routine bloods, including a group and save, must be taken urgently for all those with suspected perforation

Initial imaging via a chest radiograph (CXR) may demonstrate evidence of pneumomediastinum or intra-thoracic air-fluid levels (however do not delay definitive imaging while awaiting the CXR).

The investigation of choice is an urgent CT chest abdomen pelvis with IV and oral contrast.

If there is a high level of clinical suspicion (based on the history and examination), the patient should have an urgent endoscopy in theatre.

Question 10

CT CAP with IV contrast is the investigation of choice for oesphageal tears, what is shown on the imaging?

Answer 10

This may show air or fluid in the mediastinum or pleural cavity; leakage of oral contrast from the oesophagus into the mediastinum or chest is pathognomonic.

Question 11

What is the initial management of a oesophageal perforation?

Answer 11

These patients are often septic and haemodynamically unstable.

Urgent and aggressive resuscitation is therefore essential. Ensure high flow oxygen, fluid resuscitation, and broad spectrum antibiotics are given immediately.

Question 12

What does the definitive management of oesophageal perforation depend on?

Answer 12

Definitive management varies depending on whether the perforation was spontaneous or iatrogenic and on the age and comorbidity of the patient.

Question 13

What are the principles of definitive management (both operative and non-operative) following initial resuscitation of an oesphageal perforation?

Answer 13

The principles of definitive management (both operative and non-operative) following initial resuscitation involves:

1. Control of the oesophageal leak
2. Eradication of mediastinal and pleural contamination
3. Decompress the oesophagus (typically via a trans-gastric drain or endoscopically-placed NG tube)
4. Nutritional support

Question 14

Briefly describe the surgical management of an oesphageal perforation

Answer 14

The majority of patients with a spontaneous perforation will need immediate surgery to control the leak and wash out of the chest. This is almost always via a thoracotomy. Patients also need an on-table endoscopy to determine the site of perforation and therefore the site of the incision.

Leakage is common and the patients should have a CT scan with contrast at 10-14 days before starting oral intake. They may therefore warrant a feeding jejunostomy to be inserted at the time of surgery for nutrition.

Question 15

Why is a feeding jejunostomy sometimes needed during surgery of an oesphageal perforation?

Answer 15

Leakage is common and the patients should have a CT scan with contrast at 10-14 days before starting oral intake. They may therefore warrant a feeding jejunostomy to be inserted at the time of surgery for nutrition.

Question 16

Briefly describe the non-operative management of oesphageal perforation

Answer 16

Non-operative treatment involves:

• Initial suitable resuscitation and transfer to Intensive Care / High Dependency Unit
• Appropriate antibiotic and anti-fungal cover
• Nil by mouth for 1-2 weeks, with endoscopic insertion of an NG tube on drainage
• Large-bore chest drain insertion
• Total Parenteral Nutrition (TPN) or feeding jejunostomy insertion

Question 17

When may non-operative management be more suitable than surgery?

Answer 17

Patients with iatrogenic perforations are often more stable than those with spontaneous perforations and may be suitable for non-operative management.

Other patients potentially suitable for non-operative management include those with minimal contamination, a contained perforation, no symptoms or signs of mediastinitis, or no solid food in pleura or mediastinum.

Patients with spontaneous perforations who are too frail or with extensive co-morbidities to undergo surgery may also be candidates for non-operative treatment.

Question 18

What are Mallory-Weiss tears?

Answer 18

Mallory-Weiss tears are lacerations in the oesophageal mucosa, usually at the gastro-oesophageal junction.

Question 19

What commonly causes Mallory-Weiss tears?

Answer 19

They tends to occur after a period of profuse vomiting, and in turn results in a short period of haematemesis. They account for approximately 5% of all cases of haematemesis.

Question 20

What investigations should be ordered for Mallory Weiss tears?

Note: laboratory

Answer 20

Following your initial assess, most patients will warrant routine bloods (FBC, U&Es, LFTs, and clotting) and a VBG to be taken

• Any acute bleed may not initially show an anaemia in the FBC, whereas LFTs may reveal underlying liver damage as a potential cause
• All patients with haematemesis should have a Group and Save; those with significant haematemesis (especially suspected variceal bleed) should have at least 4 units of blood cross-matched

Question 21

What investigations should be ordered for Mallory-Weiss tear?

Note: imaging

Answer 21

The definitive investigation in most cases of haematemesis is via an oesophagogastroduodenoscopy (OGD), which also forms part of the management in cases of ongoing unstable bleeding. This should be performed within 12hrs in most cases of acute haematemesis or as soon as possible if the patient is unstable.

An erect CXR may also be required if a perforated peptic ulcer is suspected as the underlying cause.

CT abdomen with IV contrast (triple phase) can be useful in assessing any active bleeding in an unstable patient, especially if endoscopy is unremarkable or the patient is too unwell to undergo invasive investigation.

Question 22

Briefly describe the management of Mallory-Weiss tear

Answer 22

Most cases can be managed conservatively, rarely warranting interventional or surgical management.