Esophageal rupture resident survival guide
Synonyms and keywords:Approach to esophageal perforation, Boerhaave syndrome workup, Esophageal rupture workup

# Overview
Esophageal rupture is a severe condition often caused by esophageal instrumentation, including endoscopy. It also occurs from forceful vomiting, retching and swallowing of a foreign body resulting in leakage of air, stomach acid and food content into the mediastinum. Such spontaneous rupture is also known as Boerhaave syndrome. This leakage leads to severe inflammation of mediastinum called mediastinitis and pleural effusion. Symptoms can range from chest pain, dyspnea, hematemesis to hypotension and shock. Time is crucial when diagnosing the rupture of the esophagus since it impacts the complication that emerges from it. The reason for this is the specific position of the esophagus, resulting in severe mediastinitis, empyema, and septic shock during leakage of bacteria and digestive enzymes. Esophageal injuries arising from penetrating trauma are frequently associated with injuries to other organs such as the liver, spleen, aorta, vena cava, diaphragm and lungs. Diagnostic modalities include CT Scan, esophagography with water-based contrast and flexible esophagoscopy. Treatment requires surgical reconstruction of perforation, and the procedure is highly dependent on the location of the injury. (i.e. cervical, thoracic, etc.) However, endoscopic stent or placement of internal or external drains is considered when the clinical situation allows for a less invasive approach.

# Causes

## Life Threatening Cause
Life-threatening cause means the condition may result in death or permanent disability within 24 hours if left untreated.
- Traumatic injury to the esophagus that is secondary to penetrating or blunt forces including gun shot wounds. 

## Common Causes
- Iatrogenic perforations
Diagnostic endoscopy
Flexible endoscopy
Pneumatic dilation
Stent placement
Foreign body extraction
Cancer palliation
Endoscopic ablation techniques
- Diagnostic endoscopy
- Flexible endoscopy
- Pneumatic dilation
- Stent placement
- Foreign body extraction
- Cancer palliation
- Endoscopic ablation techniques
- Invasive surgical manoeuvres
Fundoplication
Esophageal myotomy
- Fundoplication
- Esophageal myotomy
- Spontaneous ruptures - Boerhaave syndrome
- Ruptures secondary to a foreign body impaction
- Ingestion of caustic liquids

# Diagnosis
Chest pain is the most commonly occurring symptom. It can be sudden in onset with radiation to the back or the left shoulder. Additional symptoms include vomiting and shortness of breath. The triad of vomiting, chest pain and subcutaneous emphysema is known as the Mackler triad.
On Physical Examination, tachycardia is usual with fever (> 38.5  C) as a later sign. Attention should be given as to whether there is crepitus in the neck area or on the chest wall, as this is typical of subcutaneous emphysema. Systemic inflammatory response typically develops rapidly after perforation, usually within 24-48 hours, and severe bacterial mediastinitis may cause cardiopulmonary collapse and multiple organ failure (MOF) with a catastrophic outcome within a limited period of time.

# Treatment

# Do's
- Check for crepitus in the neck or the chest wall.
- Check for vital signs for shock (low blood pressure, Increased heart rate).
- Always manage the life-threatening conditions first incase of traumatic rupture.

# Don'ts
- Delay the treatment since mortality and morbidity is directly related to the delay in diagnosis and initiation of optimum treatment.
- Eat or drink until the treatment is completed.