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Merck Manual
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Professional /
Gastrointestinal Disorders /
Esophageal and Swallowing Disorders /
... /
Esophageal Rupture /
IN THIS TOPIC

Symptoms and Signs

Diagnosis

Treatment

OTHER TOPICS IN THIS CHAPTER

Esophageal and Swallowing Disorders
Overview of Esophageal and Swallowing Disorders
Achalasia
Cricopharyngeal Incoordination
Diffuse Esophageal Spasm
Dysphagia
Dysphagia Lusoria
Eosinophilic Esophagitis
Esophageal Diverticula
Esophageal Motility Disorders
Esophageal Rupture
Esophageal Web
Gastroesophageal Reflux Disease (GERD)
Hiatus Hernia
Infectious Esophageal Disorders
Lower Esophageal Ring
Mallory-Weiss Syndrome
Obstructive Disorders of the Esophagus

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Esophageal Rupture

By

Kristle Lee Lynch

, MD, Perelman School of Medicine at The University of Pennsylvania

Last full review/revision Jul 2019| Content last modified Jul 2019
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Esophageal rupture may be iatrogenic during endoscopic procedures or other instrumentation or may be spontaneous (Boerhaave syndrome). Patients are seriously ill, with symptoms of mediastinitis. Diagnosis is by esophagography with a water-soluble contrast agent. Immediate surgical repair and drainage are required.

(See also Overview of Esophageal and Swallowing Disorders.)

Endoscopic procedures are the primary cause of esophageal rupture, but spontaneous rupture may occur, typically related to vomiting, retching, or swallowing a large food bolus. The most common site of rupture is the distal esophagus on the left side. Acid and other stomach contents cause a fulminant mediastinitis and shock. Pneumomediastinum is common.

Symptoms and Signs

Symptoms of esophageal rupture include chest and abdominal pain, fever, vomiting, hematemesis, and shock. Subcutaneous emphysema is palpable in about 30% of patients. Mediastinal crunch (Hamman sign), a crackling sound synchronous with the heartbeat, may be present.

Diagnosis

  • Chest and abdominal x-rays

  • Esophagography

Chest and abdominal x-rays showing mediastinal air, pleural effusion, or mediastinal widening suggest the diagnosis.

Diagnosis of esophageal rupture is confirmed by esophagography with a water-soluble contrast agent, which avoids potential mediastinal irritation from barium. CT of the thorax detects mediastinal air and fluid but does not localize the perforation well. Endoscopy may miss a small perforation.

Treatment

  • Endoscopic stenting or surgical repair

Pending surgical repair or endoscopic stenting, patients should receive broad-spectrum antibiotics (eg, gentamicin plus metronidazole or piperacillin/tazobactam) and fluid resuscitation as needed for shock. Even with treatment, mortality is high.

Drugs Mentioned In This Article

Drug Name Select Trade
piperacillin/tazobactam
 ZOSYN
metronidazole
 FLAGYL
gentamicin
 GENOPTIC
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© 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)
Esophageal Motility Disorders
Esophageal Web
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Overview of Esophageal and Swallowing Disorders Overview of Esophageal and Swallowing Disorders
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