Esophageal Rupture

What is an esophageal rupture?

Your esophagus is the swallowing tube that connects your mouth to your stomach. A rupture in your esophagus means a hole, perforation or tear through the esophagus wall. This is very serious.

Your esophagus passes through your chest cavity (thorax), right between your lungs. As part of your gastrointestinal tract, it carries the solids and liquids you ingest as well as bacteria and body chemicals belonging to your digestive system.

These contents are harmful when they escape your GI tract and leak into other places in your body. If they leak from your esophagus, they can cause an infection in your chest, lungs or bloodstream.

These infections can be life-threatening, so finding and managing them quickly is paramount. An esophageal rupture should be treated within 24 hours for the best outcome. This may mean endoscopic or surgical treatment.

How common are esophageal ruptures?

Esophageal ruptures are rare. In the United States, they occur in .003% of the population.

What is the difference between an esophageal rupture and a Mallory-Weiss tear?

A Mallory-Weiss tear is a split or tear in the inner lining of your esophagus. It doesn’t go all the way through the wall of your esophagus.

What is the difference between an esophageal rupture and an esophageal variceal rupture?

An esophageal variceal rupture is a rupture of swollen veins in your esophagus. It might bleed a lot, but it isn’t a rupture of your esophagus itself.

How do you get an esophageal rupture?

A rupture is usually caused by an injury to your esophagus. Your esophagus can be injured from the outside or the inside. Some injuries occur suddenly during a traumatic event, and some progress slowly.

More rarely, your esophagus can rupture spontaneously under tremendous stress. This is also called an effort rupture, or Boerhaave’s syndrome. It usually happens during forceful and repeated vomiting.

What is the most common cause of an esophageal rupture?

Most injuries that cause esophageal ruptures occur during medical procedures, especially endoscopic procedures that treat your esophagus through the endoscope. These are called iatrogenic ruptures.

What are the other possible causes?

Other causes of esophageal ruptures include:

• Surgical procedures on your esophagus, especially Nissen fundoplication and myotomy.
• Excessive strain during vomiting, weightlifting, seizure or childbirth.
• Swallowing a foreign object or caustic chemical.
• Blunt or penetrating injury to your esophagus, such as a stab, gunshot or car crash impact.
• Chronic acid reflux, when acid causes ulcers in the esophagus that eat all the way through.
• Sustained pressure from a tumor or foreign object in your esophagus, causing tissue death.

What risk factors contribute to a ruptured esophagus?

Your esophagus doesn’t have an outer lining (serosal layer) like most of your organs do. This makes it more vulnerable to rupture in general. It’s especially vulnerable if the inner lining is inflamed or injured.

This might be the case if you have a history of:

• Chronic acid reflux (GERD).
• Eosinophilic esophagitis.
• Esophageal diverticulum.
• Esophageal cancer or esophageal exposure to radiation therapy.
• Alcohol use.
• Surgery on your esophagus.

What are the symptoms of an esophageal rupture?

Common symptoms of an esophageal rupture include:

• Chest pain.
• Difficulty swallowing.
• Shortness of breath.
• Fast heart rate.
• Nausea.
• Vomiting blood.
• Low blood pressure.
• Fever.

Most ruptures occur in the middle to lower section of the esophagus, which is in your chest. If your rupture is higher or lower in your esophagus, you might feel pain in your neck, abdomen or right shoulder blade.

What are the possible complications of an esophageal perforation?

When gastrointestinal contents leak through the hole in your esophagus, they can cause:

• Chemical inflammation (pleurisy) of the lining of your chest cavity (pleura.)
• A build-up of fluid in your pleura (pleural effusion), which can cause it to rupture.
• Trapped air (mediastinal emphysema) in the space between your lungs (mediastinum.)
• Inflammation leading to tissue death (necrosis) in your pleura or mediastinum.
• Bacterial infection of your bloodstream (septicemia.)
• Sepsis, a life-threatening reaction to septicemia that ends in septic shock and organ failure.

How do you know if your esophagus is ruptured?

If you suspect you have a rupture, go to the E.R. right away. Severe pain and difficulties swallowing or breathing are emergency symptoms. Tell a healthcare provider what was happening when they started.

If your symptoms started immediately after an injury, swallowing something you shouldn’t have or an episode of violent vomiting, an esophageal rupture is possible. Your provider will look for the evidence.

How is a ruptured esophagus diagnosed?

A healthcare provider will order imaging of your esophagus to look for a rupture. They will usually begin with a chest X-ray. They’ll look for evidence of leaked fluids or air pockets in your chest tissues.

To confirm their findings, they may order a more sensitive type of X-ray called an esophagram. For this test, you swallow a contrast dye solution that will highlight the inside of your esophagus on the X-ray.

A contrast-dye esophagram can help providers locate the rupture in your esophagus if they’re having trouble finding it. They’ll be able to see the dye leaking through the perforation, and how fast it leaks.

They may also suggest a CT scan, especially if they suspect a rupture in the upper or lower portion of your esophagus. A CT scan can find pockets of leaked fluids in your neck or abdomen that may need draining.

What is the treatment for an esophageal rupture?

Standard treatment includes:

• IV fluids: To restore volume lost by bleeding, vomiting or difficulty swallowing water.
• IV antibiotics +/- antifungals: To prevent or treat any infections.
• IV nutrition or tube feeding: You won’t be able to swallow food during treatment or recovery.
• Percutaneous fluid drainage: Any infected fluid collections that have leaked into your body cavities may need to be drained and sterilized to prevent infection. Your provider will attempt to address this as soon as possible by draining through a needle or tube inserted into your chest.
• Endoscopic treatment: Some minor ruptures may be treatable by endoscopy instead of surgery. An endoscope is a long catheter with a camera on the end that is passed down your throat into your esophagus. An endoscopist may place clips, sutures, a vacuum sponge or a stent via the endoscope.
• Surgery: Some people will need surgery to directly repair the rupture. During surgery, your surgeon will drain any excess fluid and remove dead (necrotic) tissue. Depending on your condition, your surgeon may be able to use a minimally invasive surgery technique like video-assisted thoracoscopic surgery (VATS). But some emergency cases may be better managed by open surgery — opening up your full thoracic (chest) cavity to allow better and speedier access.

Can you survive an esophageal rupture?

Yes, but your prognosis depends on how soon you receive treatment. The more time infections have to spread from the rupture through your chest cavity and bloodstream, the more at risk you are.

Those who receive treatment within the first 24 hours of rupture are likely to make a full recovery. The survival rate in this group is 85%. After 48 hours without treatment, the survival rate falls to 50%.