Oesophageal Tears

Question 1

What are oesophageal tears?

Answer 1

Ruptures to any part of the oesophageal wall.

Full ruptures have a mortality between 50-80% (luckily they are rare)

Question 2

What are the main two subcategories?

Answer 2

Superficial mucosal tears (Mallory-Weiss tears)

Full thickness ruptures

Question 3

What is oesophageal perforation?

Answer 3

A full thickness rupture of the oesophageal wall.

Question 4

What is Boerhaave’s syndrome+

Answer 4

A spontaneous full rupture, often due to vomiting.

Question 5

Complication of oesophageal perforation

Answer 5

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

Question 6

Causes of oesophageal perforation

Answer 6

Iatrogenic (via endoscopy e.g.)

Severe forceful vomiting

Question 7

Most common site of perforation

Answer 7

Just above the diaphragm in the left postero-lateral position.

It can occur elsewhere as well.

Question 8

Clinical features of oesophageal perforation

Answer 8

Severe sudden-onset of retrosternal chest pain

Respiratory distress

Subcutaneous emphysema (frequently absent)

Followed by severe vomiting or retching.

Question 9

What is Mackler’s triad?

Answer 9

Subcutaneous emphysema

Vomiting

Chest pain

Question 10

Investigations of oesophageal perforation

Answer 10

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.

Question 11

X-ray findings of oesophageal perforation

Answer 11

Evidence of pneumomediastinum

Intra-thoracic air-fluid levels

Question 12

Findings of urgent CT chest abdomen pelvis with IV and oral contrast in oesophageal perforation

Answer 12

Air or fluid in the mediastinum or pleural cavity.

Leakage of oral contrast from the oesophagus into the mediastinum or chest.

Question 13

Initial management of oesophageal perforation

Answer 13

Often septic and haemodynamically unstable so urgent and aggressive resuscitation is important.

High flow o2

Fluid resus

Broad spectrum abx

Question 14

What does definitive management of oesophageal perforation depend on?

Answer 14

Whether rupture was spontaneous or iatrogenic

Age

Comorbidities

Question 15

Principles of definitive management of oesophageal perforation

Answer 15

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.

Question 16

Types of management of oesophageal perforation

Answer 16

Surgical

Non-surgical

Question 17

Surgical management of oesophageal perforation

Answer 17

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.

Question 18

Post-op management of oesophageal perforation

Answer 18

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.

Question 19

Indications of non-surgical intervention.

Answer 19

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

Question 20

Why are iatrogenic perforations usually more stable?

Answer 20

Because patient will usually been nil by mouth by the time of the perforation.

It is not associated with forceful vomiting so less contamination.

Question 21

Types of non-operative treatment

Answer 21

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

Question 22

Prognosis of oesophageal perforation

Answer 22

Morbidity and mortality is high (50-80%)

Question 23

What are Mallory-Weiss tears MWT?

Answer 23

Lacerations in the oesophageal mucosa usually at the gasto-oesophageal junction.

Question 24

What causes MWTs?

Answer 24

Period of profuse vomiting leading to a short period of haematemesis.

Question 25

Complications of MWTs

Answer 25

Usually small and self-limiting in absence of clotting abnormalities or anti-coagulation drugs

Haemorrhagic shock can happen but is rare.

Question 26

Ix of MWTs

Answer 26

Discussed in Haematemesis section.

Question 27

Management of MWTs

Answer 27

Managed conservatively generally