Oesophageal Tears

Question 1

what is a Oesophageal tear

Answer 1

Ruptures to any part of the oesophageal wall

Question 2

What are the two main categories of oesophageal tears

Answer 2

Superficial mucosal tears ( Mallory Weiss )

Full thickness ruptures

Question 3

What is oesophageal perf

Answer 3

Full thickness rupture of the oesophageal wall

Question 4

What is Boerhaaves syndrome

Answer 4

Spontaneous full thickness rupture of the oesophagus often due to vomiting

Question 5

What is the complication of a full thickness oesophageal rupture

Answer 5

Stomach contents leak out into the mediastinum and triggers a inflammatory response which can lead to sepsis and MODs therefore is a surgical emergency

Question 6

What are the commonest causes of oesophageal tears

Answer 6

Iatrogenic eg - endoscopy

Severe forceful vomiting

Question 7

What is the most common site of oesophageal perforation

Answer 7

Just above the diaphragm in the left posterio-lateral position

Question 8

What are the clinical features of someone presenting with a oesophageal rupture

Answer 8

Sudden onset Retrosternal pain
Resp distress ( due to leakage of stomach contents )
Subcutaneous emphysema
Vomiting

( macklers triad - vomiting, Retrosternal pain , subcutaneous emphysema )

Question 9

How would you investigate a patient with oesophageal perf

Answer 9

• Routine bloods plus group and save
• CXR - pneumomediastinum
• CT CAP with IV and oral constrast ( oral constrast will leak out of oesophagus )

Question 10

How would you initially manage a patient with oesophageal perf

Answer 10

These patients are often haemodynamically unstable and septic and require sepsis 6

• High flow O2
• IV fluids
• broad spec Abx

Question 11

What are the principles of definitive treatment of oesophageal perf

Answer 11

After having got them stable the management includes:

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 12

How is the oesophageal leak controlled for those that had a spontaneous perf

Answer 12

Surgery to close the perforation using a flap from the diaphragm and then insertion of a trans gastric drain

Question 13

What is the non-operative management for perfs caused by iatrogenic causes

Answer 13

1. Initial resuscitation ( for pts with sepsis )
2. Antibiotic and antifungal cover
3. NBM
4. Endoscopic NG tube insertion
5. Large bore chest drain
6. TPN / Feeding jejunostomy

Question 14

What are Mallory - Weiss tears

Answer 14

Superficial lacerations of the muscosa usually at the GOJ

Question 15

When do you tend to get Mallory Weiss tears

Answer 15

After a period of profuse vomiting you will get a period of haematemesis

Question 16

How would you investigate Mallory Weiss tears

Answer 16

Generally they are self limiting but if bleeding is prolonged, the use of a OGD may be warranted

Bloods - LFT,COAG FBC, CXR

Question 17

How would you manage Mallory Weiss tears

Answer 17

Generally they are self limiting however some patients may be in hypotensive shock therefore , may need a group and save and Cross match. With fluid resus