Intraluminal procedures are the most common cause of esophageal perforation. Other causes include transient increase in intraesophageal pressure (Boerhaavesyndrome), trauma, foreign body, infection, tumor, and aortic pathology. Perforation of the esophagus is associated with a high mortality rate.
Pain is classically described as acute, severe, unrelenting, and diffuse and is reported in the chest, neck, and abdomen. Pain can radiate to the back and shoulders, or back pain may be the predominant symptom. Swallowing often exacerbates pain. Physical examination varies with the severity of the rupture and the elapsed time between the rupture and presentation. Abdominal rigidity with hypotension and fever often occur early. Tachycardia and tachypnea are common. Mediastinal emphysema takes time to develop. It is less commonly detected by examination or radiography in lower esophageal perforation, and its absence does not rule out perforation. A Hammon crunch can sometimes be auscultated. Pleural effusions develop in 50% of patients with intrathoracic perforations and are uncommon in cervical perforations.
Diagnosis and Differential
Chest radiography can suggest the diagnosis. CT of the chest or emergency endoscopy is most often used to confirm the diagnosis. Selection of the procedure depends upon the clinical setting and the resources available. Pain resulting from esophageal perforation often is ascribed to acute myocardial infarction, pulmonary embolus, peptic ulcer disease, aortic catastrophe, or acute abdomen, which results in critical delays in diagnosis.
Children (18 to 48 months old) account for 80% of all cases of ingested foreign bodies. Coins, toys, and crayons typically lodge in the anatomically narrow proximal esophagus. Adult candidates are those with esophageal disease, prisoners, and psychiatric patients. In adults, most impactions are distal. Complications include airway obstruction, stricture, and perforation. Once an object transverses the pylorus, it usually continues through the GI tract. Objects that become lodged distal to the pylorus are usually irregular, have sharp edges, are wide (>2.5 cm) or long (>6 cm)
Objects lodged in the esophagus can produce retrosternal pain, dysphagia, coughing, choking, vomiting, aspiration, and the patient may be unable to swallow secretions. Adults with an esophageal foreign body generally provide unequivocal history. In the pediatric patient it may be necessary to rely on clues such as refusal to eat, vomiting, gagging, choking, stridor, neck or throat pain, dysphagia, and drooling.
Diagnosis and Differential
Physical examination starts with an assessment of the airway. The nasopharynx, oropharynx, neck, and chest should also be examined. Occasionally, a foreign body can be directly visualized in the oropharynx. Plain films are used to screen for radiopaque objects. Ingested, impacted bones can be seen on plain films only ≤50% of the time. CT scanning has replaced the barium swallow test to evaluate for nonradiopaque objects. Differential diagnosis includes dysphagia, esophageal carcinoma, and gastrointestinal (GI) reflux disease.
Emergency Department Care and Disposition
Patients in extremis or with pending airway compromise are resuscitated in standard fashion and may require active airway management.
Emergent endoscopy is indicated for complete distal obstruction of the esophagus with pooling of secretions (often distal esophageal food impaction).
Hospital admission is generally not needed if the foreign body is easily removed by endoscopy without complications.
In stable patients, indirect or fiberoptic laryngoscopy may allow removal of very proximal objects.
Consult surgery for worrisome foreign bodies that are in the more distal GI tract.
Meat is the most common cause of food impaction.
Complete esophageal obstruction requires emergency endoscopy.
Uncomplicated food impaction may be treated expectantly but should not be allowed to remain impacted for >12 to 24 hours.
The use of proteolytic enzymes (eg, Adolph Meat Tenderizer, which contains papain) to dissolve a meat bolus is contraindicated.
Glucagon (1 to 2 milligrams for adults) may be attempted but success rates are poor.
A button battery lodged in the esophagus is a true emergency requiring prompt removal because the battery may quickly induce mucosal injury and necrosis. Perforation may occur within 6 hours of ingestion.
Resuscitate the patient as needed.
Obtain radiographs to locate position of the battery.
Emergency endoscopy is indicated if battery is lodged in the esophagus. Foley balloon catheter technique may be considered if reliable history of ingestion ≤2 hours is obtained.
Batteries that have passed the esophagus can be managed expectantly with 24-hour follow-up examination. Repeat x-rays at 48 hour to ensure passage through pylorus. Most batteries pass through the body in 48 to 72 hours but may take longer.
Consult surgery if the patient develops symptoms or signs of GI tract injury.
The National Button Battery Ingestion Hotline at 202-625-3333 is a 24-hours, 7 days-a-week resource for help with management decisions.