Oesophageal perforation

Overview

Oesophageal perforation is a life-threatening emergency - full-thickness breach of the oesophageal wall allowing luminal contents to leak into surrounding structures. The oesophagus lacks a serosa, so mediastinitis develops within hours. Mortality approximately doubles when treatment is delayed beyond 24 hours.

Causes

•Iatrogenic - most common (~60%); upper GI endoscopy, dilatation, TOE, intubation, surgery

•Boerhaave syndrome - spontaneous full-thickness tear from forceful vomiting; left posterolateral distal oesophagus; highest mortality

•Foreign body - sharp objects at natural narrowing points; common in children and elderly

•External trauma - penetrating neck/chest injuries

•Tumour-related - erosion or complication of malignant stenting

Presentation

•Mackler's triad (Boerhaave): forceful vomiting → sudden severe chest/epigastric pain → subcutaneous emphysema in neck/chest wall

•Chest pain - severe, sudden, tearing or pleuritic; may radiate to back, shoulder, or epigastrium

•Subcutaneous emphysema - crepitus in neck or supraclavicular fossae; pathognomonic when present

•Hamman's sign - mediastinal crunch on auscultation synchronous with heartbeat (pneumomediastinum)

•Left-sided pleural effusion - dyspnoea, dullness at left base

•Systemic sepsis - fever, tachycardia, hypotension develop rapidly; may be absent early

🎯

Classic mimic of aortic dissection, MI, and PE. The discriminating feature is the history of forceful vomiting or recent oesophageal instrumentation immediately before the pain. Always ask: "What were you doing just before the pain started?"

Investigations

🥇 First-line

•Chest X-ray - pneumomediastinum, left pleural effusion, pneumothorax, surgical emphysema, widened mediastinum. Normal CXR does NOT exclude perforation (up to 12% normal initially)

🏆 Gold standard

•CT chest and neck with IV contrast - identifies site, extent, and complications (mediastinal fluid/gas, pleural collections); also excludes aortic dissection

🥈 Second-line

•Water-soluble contrast swallow (e.g. Gastrografin) - demonstrates leak directly; used when CT equivocal or to confirm before conservative management

•Blood tests: FBC, CRP, U&E, LFTs, clotting, group and save, blood cultures - raised WCC/CRP indicate mediastinitis/sepsis; supportive rather than diagnostic

⚠️

Barium swallow must be avoided - barium mediastinitis is extremely harmful if contrast extravasates. Use water-soluble contrast (Gastrografin) only.

Differential diagnosis

Key differentials for sudden severe chest pain after vomiting

Condition	Distinguishing features
Aortic dissection	Tearing chest/back pain; CT angiography shows aortic flap, no mediastinal contamination
Acute MI	ECG changes, troponin rise, no mediastinal air
Pulmonary embolism	Pleuritic pain + dyspnoea; CTPA shows filling defect, no mediastinal contamination
Mallory-Weiss tear	Mucosal (partial thickness) only; presents with haematemesis, not mediastinitis; managed conservatively
Perforated peptic ulcer	Free air under diaphragm; epigastric peritonism; no pneumomediastinum
Hamman syndrome	Benign spontaneous pneumomediastinum; young thin male after straining; no full-thickness tear, no sepsis

Management

•Immediate resuscitation: nil by mouth, IV access, fluid resuscitation, analgesia, oxygen

•IV broad-spectrum antibiotics and antifungals - cover mediastinal contamination

•Nasogastric tube insertion - for decompression and enteral feeding

•Urgent senior surgical/upper GI input - all patients

•Surgical repair (primary closure + mediastinal washout) - Boerhaave syndrome, large/freely communicating perforations, or contaminated mediastinum; ideally within 24 hours

•Endoscopic stenting - selected iatrogenic or contained perforations in specialist centres

•Conservative management - small, contained iatrogenic perforations with no systemic sepsis; requires close observation and low threshold to escalate

•Chest drain - for pleural effusion/empyema (typically left-sided)

🚨

Patients managed conservatively who progress to sepsis must be escalated to surgery without delay - failure to recognise conservative management failure is a major avoidable harm.

Complications

•Mediastinitis - most feared; bacteria and digestive enzymes cause fulminant inflammation and necrosis

•Empyema/pleural effusion - usually left-sided; may need chest drain or surgical decortication

•Sepsis and multiorgan failure - end-result of uncontrolled contamination

•Oesophageal fistula - oesophagopleural or oesophagobronchial; more likely with delayed diagnosis

•Stricture - late complication causing dysphagia requiring dilatation

Prognosis

•Overall mortality 10-25% with prompt treatment

•Boerhaave syndrome: mortality up to 40% even with treatment; untreated approaches 100%

•Iatrogenic perforation diagnosed immediately: mortality <5% in some series

•Poor outcome predictors: delayed diagnosis (>24 h), distal perforation, mediastinitis, septic shock, malignant oesophagus, advanced age