Oesophageal Tears Flashcards
What are oesophageal tears?
Ruptures to any part of the oesophageal wall.
Full ruptures have a mortality between 50-80% (luckily they are rare)
What are the main two subcategories?
Superficial mucosal tears (Mallory-Weiss tears)
Full thickness ruptures
What is oesophageal perforation?
A full thickness rupture of the oesophageal wall.
What is Boerhaave’s syndrome+
A spontaneous full rupture, often due to vomiting.
Complication of oesophageal perforation
The perforation will cause leakage of stomach contents into the mediastinum + pleural cavity.
This triggers a severe inflammatory response which will rapidly become overwhelming.
This leads to physiologyical collapse, multiorgan failure and death.
Oesophageal rupture is a surgical emergency
Causes of oesophageal perforation
Iatrogenic (via endoscopy e.g.)
Severe forceful vomiting
Most common site of perforation
Just above the diaphragm in the left postero-lateral position.
It can occur elsewhere as well.
Clinical features of oesophageal perforation
Severe sudden-onset of retrosternal chest pain
Respiratory distress
Subcutaneous emphysema (frequently absent)
Followed by severe vomiting or retching.
What is Mackler’s triad?
Subcutaneous emphysema
Vomiting
Chest pain
Investigations of oesophageal perforation
Routine bloods + G&S
CXR
Urgent CT chest abdomen pelvis with IV and oral contrast
If there is a high level of clinical suspicion the patient should have an urgent endoscopy in theatre.
X-ray findings of oesophageal perforation
Evidence of pneumomediastinum
Intra-thoracic air-fluid levels
Findings of urgent CT chest abdomen pelvis with IV and oral contrast in oesophageal perforation
Air or fluid in the mediastinum or pleural cavity.
Leakage of oral contrast from the oesophagus into the mediastinum or chest.
Initial management of oesophageal perforation
Often septic and haemodynamically unstable so urgent and aggressive resuscitation is important.
High flow o2
Fluid resus
Broad spectrum abx
What does definitive management of oesophageal perforation depend on?
Whether rupture was spontaneous or iatrogenic
Age
Comorbidities
Principles of definitive management of oesophageal perforation
Following initial resus…
1 - Control of the oesophageal leak
2 - eradication of mediastinal and pleural contamination
3 - decompress the oesophagus (by trans-gastric drain or NG tube)
4 - nutritional support.
Types of management of oesophageal perforation
Surgical
Non-surgical
Surgical management of oesophageal perforation
Majority of patient with a spontaneous perforation require immediate surgery.
This is done by thoracotomy and the patient also need an on-table endoscopy to determine the site of perforation and therefore the site of the incision.
Post-op management of oesophageal perforation
Leakage is common -> CT scan with contrast at 10-14 days before starting oral intake
Feeding jejunostomy at time of surgery might be placed to support nutrition.
Indications of non-surgical intervention.
Iatrogenic perforations are often more stable and may be suitable for conservative management.
Minimal contamination
Contained perforation
No symptoms or signs of mediastinitis
No solid food in pleura or medastinum.
Too frail
Extensive co-morbidities
Why are iatrogenic perforations usually more stable?
Because patient will usually been nil by mouth by the time of the perforation.
It is not associated with forceful vomiting so less contamination.
Types of non-operative treatment
Initial suitable resus and transfer to ICU
Appropriate abx and anti-fungal cover
NBM for 1-2 weeks with NG tube on drainage
Large-bore chest drain insertion
Total parenteral nutrition or feeding jejunostomy insertion
Prognosis of oesophageal perforation
Morbidity and mortality is high (50-80%)
What are Mallory-Weiss tears MWT?
Lacerations in the oesophageal mucosa usually at the gasto-oesophageal junction.
What causes MWTs?
Period of profuse vomiting leading to a short period of haematemesis.
Complications of MWTs
Usually small and self-limiting in absence of clotting abnormalities or anti-coagulation drugs
Haemorrhagic shock can happen but is rare.
Ix of MWTs
Discussed in Haematemesis section.
Management of MWTs
Managed conservatively generally
