Oesophageal tears Flashcards
What are oesophageal ruptures?
- Ruptures to any part of oesophageal wall
- Complete ruptures have high mortality
- Wide spectrum of severity - superficial Mallory Weiss and full thickness Boerhaaves syndrome
What is oesophageal perforation?
- Full thickness rupture of oesophageal wall
- If spontaneous (often due to vomitting) is called Boerhaaves syndrome
Consequence of perforation
- Leakage of stomach contents into mediastinum and pleural cavity
- –> severe sepsis, physiological collapse, multi-organ failure and death
Common causes of oesophageal perf
- Iatrogenic eg endoscopy
- Severe forceful vomitting - Boerhaave
Common site of oesophageal perfs
- Just above diaphragm
- In left postero-lateral position
- 2-3cm proximal to gastro-oesophageal junction
Symptoms of oesophageal perforation
- Severe sudden onset retrosternal chest pain
- Respiratory distress
- Subcutaneous emyphysema following severe vomitting/retching
Triad for oesophageal perf
- Macklers triad
- Vomitting, chest pain and subcutaenous emphysema
- Not seen very often - only 15%
Examination of patients with oesphageal perforation
- Critically unwell - features of severe sepsis
- Intra-thoracic occuring so abdominal signs may be absent
- Chest exam - dullness, reduced air entry due to pleural effusion
Bedside and bloods for ?oesophageal perf
- FBC
- CRP
- Group and save
Imaging for ?oesophageal perf
- Initial usually CXR - pneumomediastinum or intrathoracic air fluid levels
- Urgent CT chest abdomen pelvis + IV and oral contrast - investigation of choice - may show air/fluid in mediastinum/pleural cavity, if leakage of oral contrast into mediastinum = pathognomonic
What contrast should be used for oesophageal perf?
- Water soluble contrast - prevent worsening of inflammation due to leakage into thoracic cavity
What to do if imaging inconsistent with clinical suspicion of oesophageal perf?
Urgent endoscopy in theatre
Management of oesophageal perfs - principles
Sepsis 6 usually as septic - broad spec abx and antifungals
Principles of management are:
* Control oesophageal leak - account for distal obstruction
* Eradication of mediastinal and pleural contamination
* Decompress oesophagus - transgastric drain or endoscopic NG tube
* Nutritional support
Surgical management oesophageal perf - principles
- Drainage intrathoracic contamination - via large bore surgical chest drain (under sedation), in theatre or A&E
- Immediate surgery - control leak and washout via thoracoctomy +/- laparatomy depending on site of perf
- On table endoscopy determine site and assess for distal obstruction
Surgical options oesophageal perf
- Primary repair
- Resection
- Diversion/exteriorisation via oesophagectomy
- Or washout and place drains
What should all patients have post surgery for oesophageal perf?
- Repeat CT scan with oral contrast as leakage is common - at 10-14 days before restarting oral intake
- May need jejunostomy for feeding at time of initial surgery
Non-operative management oesophageal perf - when
- Iatrogenic perforations - more stable than spontaneous
- Minimal contamination
- Contained perforation
- No symptoms/signs of mediastinitis
- Too frail or extensive co-morbids for surgery
Why are iatrogenic perfs more stable than spontaneous?
- Patient is usually NBM before procedure so no forceful vomitting associated and not as much contamination
Non-operative management oesophageal perf
- Urgent resuscitation and transfer to ICU or high dependency unit
- Abx and antifungal cover
- Endoscopic therapy - clips, covered stents, suturing, vaccum
- NBM - 1-2 weeks, NG tube inserted endoscopically for drainage
- Large bore chest drain - surgical or US guided
- TPN or feeding jejunostomy
What are Mallory Weiss tears?
- Lacerations in oesophageal mucosa usually at GOJ
- Tend to occur after period of profuse vomitting and cause short period of haematemesis
Management of mallory weiss tears
- Conservative - usually self limiting in absence of clotting abnormalities or anticoags
