Perforation( or perforation) of the esophagus is a rare pathology that occurs in only 1% of patients in thoracic surgery departments, with 15% of this number accounting for an even more rare disease called Burkhawe syndrome( or spontaneous esophagus rupture).This disease is three times more likely to affect male patients.
In the general structure of the disease, about 25% of the cases are pathologies of the cervical esophageal tube, resulting from iatrogenic interventions( therapeutic, diagnostic, preventive manipulations that lead to undesirable consequences), penetrating neck injuries and getting all kinds of foreign bodies.
Spontaneous ruptures, as a rule, are subjected to the intra-abdominal department of the esophageal tube, of which only a fourth is caused by wounds;all others are the result of endoscopic medical procedures.
The term
The term "perforation of the esophagus" means a condition accompanied by a violation of the integrity of the walls of the esophageal tube, as a result of which its contents( food and liquid) enter the surrounding space, provoking the emergence of an acute inflammatory process( purulent mediastinitis).
Treatment of perforation of the esophageal tube is performed exclusively by surgery. This serious condition often ends in a fatal outcome.
Causes of esophagus rupture
- Most often( more than 80% of cases) perforation of the esophagus occurs due to iatrogenic causes. For example, when endoscopic procedures are performed by patients suffering from diseases( strictures, cancer, esophagitis) leading to thinning of the walls of the stomach and esophagus. In these cases, the esophagus can be damaged from the inside during a blind( without the use of X-ray and esophagoscopic control) bougie using the Blackmore probe. No less traumatic can be the use of nasogastric tube( device for artificial feeding of the patient), esophagoscope, biopsy forceps, intubation tube.
- Thinning of the esophageal walls with their subsequent perforation can occur during sclerotherapy sessions( a technique often used to treat varicose veins of the esophageal tube) and in patients suffering from radiation and drug esophagitis.
- Cases of spontaneous perforation( the so-called Burhave syndrome) can be observed in situations that trigger a sharp jump in intraosophageal pressure: during labor, with indomitable vomiting, attacks of coughing and when heavy weights are lifted.
- A very dangerous traumatic factor accompanied by massive disruption of the integrity of the esophageal walls and organs adjacent to the esophagus is chemical burns that occur when alkalis and acids are ingested( this often happens during suicide attempts).
- The reason for the perforation of the esophagus may be the ingress of any foreign body into it. In this case, damage to the esophageal walls may result from: exposure to the foreign object itself, attempts to extract it, or because of pressure sores resulting from prolonged stay of the object in the cavity of the esophagus. The consequences of swallowing batteries used to charge watches and electronic devices are especially dangerous. In this case, the esophagus tissues may suffer as a result of: necrosis, which has developed from the pressure of a heavy metal object;exposure to alkali, which is part of the electrolyte;effects of a weak electric charge. In the medical literature, cases of penetration( penetration) of such batteries into the aortic lumen are described.
In cases where the perforation of the esophagus has occurred due to traumatic injury, it is customary to indicate its mechanism. The cause of traumatic perforation of the esophageal tube can be:
- Wound( cut, stabbed, gunshot, stuck with a blunt object).
- Careless execution of medical manipulation.
- Exposure of foreign matter.
- Spontaneous, hydraulic or pneumatic fracture.
The level of mortality in traumatic injuries of the esophagus is quite high and varies between 30-50%.
The risk group for this disease includes patients suffering from the ulcer of the esophagus and any form of esophagitis. The perforation of the esophagus in them can occur with:
- habits of overeating;
- attacks of profuse vomiting;
- overly intense exercise.
- The first sign of perforation of the esophagus is the presence of profuse vomiting, which is indomitable. In vomit masses, an admixture of blood is noticeable: it first has a scarlet color, and then it becomes like a coffee grounds.
- Vomiting is accompanied by the appearance of severe acute pain, localized behind the breastbone and in the stomach. Divers( irradiating) in the left arm or in the scapula, they can mimic the symptoms of a perforating ulcer or myocardial infarction.
- Immediately after perforation of the esophagus, subcutaneous emphysema arises and rapidly increases( the so-called condition in which air coming from a damaged esophagus accumulates first in the tissues of subcutaneous tissue on the chest wall and then spreads to other parts of the body), covering the neck, face and thoraciccell.
- When listening to( auscultation) of the heart in patients with perforation of the esophagus, the doctor can hear sounds resembling crackling cellophane film. This symptom, called hammen cremation, is explained by the presence of air in the tissues of the mediastinal tissue.
- If the lesions of the esophagus are multiple in nature, the patient's breathing( due to significant compression of the lungs and heart muscle) becomes difficult;there is severe shortness of breath.
- In the first hours after the onset of the pathology, the patient shows increasing signs of shock, manifested in the pallor of the skin, the presence of tachycardia( accelerated heart beat) and arterial hypotension( a significant decrease in blood pressure).
- In some( in every tenth case) part of elderly patients, clinical manifestations of perforation of the esophageal tube may be completely absent. A few hours later, as a result of the rapid multiplication of pathogenic microflora contained in saliva and penetrated into the mediastinum through the hole formed in the esophageal wall, the development of the septic inflammatory process( mediastinitis) begins in the patient's body. Acute mediastinitis is accompanied by high fever, the appearance of fever and tremendous chills, severe chest pains and severe intoxication. A clinical analysis of the blood taken from the patient at this time will show an elevated white blood cell count and an increased erythrocyte sedimentation rate. The patient's condition can worsen right before his eyes.
Symptoms of esophageal perforation
The perforation of the esophagus, which occurred at the level of the cervical region, is fraught with the development of phlegmon( purulent inflammation of fatty tissue) of the neck;with damage to the intrathoracic department, mediastinitis almost always develops, as well as pericarditis( inflammation of the pericardium - pericardial sac) and pleurisy( inflammatory lesions of serous membranes covering the lungs);defeat of the abdominal part of the esophagus is dangerous development of peritonitis( inflammation of the peritoneum).
Regardless of the location of the lesion, all cases of perforation of the esophagus are accompanied by an increase:
- shock;
- toxemia( poisoning of the organism with toxins of microorganisms multiplying in the lesion);
- cardiovascular and respiratory failure.
Due to the similarity of some clinical manifestations, the perforation of the esophagus should be differentiated with the cases:
- pulmonary thromboembolism and myocardial infarction - ailments accompanied by symptoms of cardiogenic shock;
- entering the cavity of the esophageal tube of a foreign body, which did not lead to its rupture;
- perforated gastric ulcer;
- spontaneous pneumothorax - a pathological condition in which there is a sudden disruption of the integrity of the serosa of the lungs, provoking the flow of air from the lung tissue into the pleural cavity;
- diaphragm rupture;
- of Mallory-Weiss syndrome - a condition characterized by the occurrence of superficial longitudinal ruptures of the mucous membranes of the distal esophagus and the upper( cardiac) stomach that arise during repeated seizures associated with inevitable bleeding;
- infringement of a hernia of an esophageal aperture of a diaphragm;
- of Hammain syndrome( in very rare cases observed in the process of stimulation of labor), taking place in an acute form and accompanied by the appearance of fever, cough with a lot of sputum and rapidly developing dyspnea.
Diagnosis
Suspected esophagus perforation is an indication for immediate chest and abdominal x-ray examinations. There are two options for X-ray examination: with and without radiopaque.
- X-ray examination with the introduction of radiopaque substance provides more complete and reliable information about the size of the resulting perforation of the esophageal tube, as well as the presence of lesions in adjacent organs and tissues. After the patient drinks a suspension of barium sulfate, a specialist radiologist performs a series of shots( the patient will be asked alternately to lie on his back, on his side and on his stomach).Due to different projections of images, it is possible to trace the movement of the radiopaque fluid through the perforation defect of the esophagus into the mediastinal cavity. After the pictures are taken, the patient is given a glass with warm boiled water and is asked to take two or three drinks. This allows you to wash the radiopaque fluid from the walls of the esophagus, leaving intact that part of it that penetrated the mediastinum.
- X-rays that do not involve contrast are not as comprehensive as the nature of the lesions. Pictures obtained during such a study will allow only indirectly to judge the presence of a perforation opening in the esophageal tube. The basis for such a judgment will serve only the apparent displacement of the lungs and heart muscle, which occurred due to the pressure exerted by a significant mass of air.
- After radiographing the patient is sent to the office of an endoscopist to identify the presence of indications and contraindications to subsequent endoscopic examinations of the gastrointestinal tract. During the consultation the endoscopist, having familiarized himself with the records in the medical record, will compare them with the history of the disease and complaints of the patient, after which he will find out whether he has any allergic predisposition. All this information is necessary for the selection of an endoscopic procedure( in parallel, a variant of anesthetic measures is thought out), which is optimal for a particular patient. Explaining to the patient the features of the planned study and the rules of preparation for it, the doctor will necessarily appoint the exact date of the procedure.
- To determine the exact location and configuration of the perforation, and at the same time to carry out surgical treatment, an esophagoscopy procedure involving the use of a rigid endoscope is performed. This manipulation is carried out without forcing air into the esophagus, because Mezrin or Brunnings devices used to perform it, do not need this. After a diagnostic examination of the state of the esophagus, the specialist will carry out a therapeutic procedure for the sanation of the formed false path in the mediastinum, consisting in the release of the pathological cavity in the tissues of the near-esophageal cellulose from food residues, radiopaque substance and pus. Another purpose of esophagoscopy is the safe( since it is possible to visually control) carrying an orogastric tube into the stomach for the purpose of feeding the patient. This manipulation is carried out in cases when the usual variant of feeding( through the mouth) is impossible.
- With the help of computed tomography of the chest in the case of rupture of the esophagus, the presence of air and abscesses in the mediastinal cavity, as well as places of gas accumulation and a horizontal level of fluid, are revealed. The procedure of computed tomography, involving the introduction of radiopaque substances, allows you to accurately determine the fact of its emergence beyond the contours of the damaged esophagus. This diagnostic technique allows to determine the exact localization of the rupture, the size( length and width) and the direction of the fistula formed, as well as the nature of its communication with the organs and structures of the mediastinum.
- The electrocardiography procedure is mandatory with respect to patients belonging to the middle and older age category in order to exclude the presence of myocardial infarction, which has a similar clinical symptomatology.
- The procedure for ultrasound examination of pleural cavities helps to detect the presence of free fluids in them.
Treatment of
The leading role in the treatment of cases of perforation of the esophagus is given to surgical intervention. In the course of its implementation, surgeons solve many problems.
The following operations are of primary importance:
- By opening and draining the damaged parts of the esophageal tube.
- Directed on elimination of perforation defect. This group of surgical interventions includes resection of the esophagus and suturing perforations, followed by sealing of the superimposed seams.
- Allowing to provide enteral nutrition of the patient with special mixtures introduced into his body through different kinds( for example, nasogastric or nasoduodenal) of gastric probes, and also through probes inserted into the stoma.
The extent and type of surgical interventions in each case depends on the state of the esophageal walls, as well as on the presence of concomitant diseases and damage to organs located in the neighborhood.
As a rule, the best results are given by surgical treatment performed during the first day after the esophagus was perforated.
Conservative treatment may be prescribed:
- For minor lesions of the esophagus( for example, if it is injured by a biopsy needle or fishbone) that did not affect other mediastinal organs.
- In the presence of iatrogenic perforation, the diameter of which does not exceed 1.5 cm, and the length is 2 cm. The outflow of pus in the lumen of the esophageal tube should be satisfactory, and the surrounding organs and mediastinal pleura should not have the slightest damage.
- When a sclerosed esophageal tube ruptures. Since the formation of scars occurs in the structures of the perisophageal tissue, there is no threat of pus spread in this case.
Conservative treatment of patients with the Burkhawe syndrome, providing for the intake( oral and intramuscularly) of broad-based antibiotics, is carried out only under stationary conditions, since their nutrition will be carried out either through a probe inserted into the stomach or through a gastrostomy( artificial entrance to the stomach through the anterior abdominal wall).
Treatment of such patients can be organized in the surgical and gastroenterological departments of hospitals.
Prognosis and prophylaxis
The level of postoperative lethality in the Burkhawe syndrome is quite high and fluctuates over a wide range: from 25 to 85%.
The main guarantee for the success of treatment is the time that has elapsed since the injury of the esophagus, since the belated diagnosis is dangerous due to the development of severe purulent complications represented by:
- sepsis;
- phlegmon neck;
- by esophageal-respiratory fistula;
- of the empyema of the pleura;
- by arthrosis( arising from the violation of the integrity of the vascular walls) by bleeding;
- by mediastinite.
If the operation was performed 48 hours after the occurrence of an esophagus rupture, the chance of survival remains in no more than 10% of patients. Complete absence of adequate treatment means almost 100% lethal outcome.
Prophylaxis of perforation of the esophagus, which is secondary in nature, should first of all be aimed at preventing diseases that can provoke the development of this condition.
Another way to prevent the development of esophageal tube ruptures is the timely detection( with subsequent treatment) of patients suffering from bulimia( a passion for overeating).
Medical personnel responsible for conducting endoscopic procedures are required to take all measures to prevent iatrogenic damage to the esophagus.