Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Suspect after forceful emesis or instrumentation with chest pain; obtain CT with contrast.
- Keep NPO; start broad antibiotics (± antifungals); consult surgery/GI early.
- Definitive control: primary repair or endoscopic stent ± drainage based on timing and contamination.
- ICU monitoring; nutritional support; follow‑up imaging to confirm healing.
Clinical Synopsis & Reasoning
Full‑thickness esophageal rupture after forceful emesis presents with chest/epigastric pain and subcutaneous emphysema. Diagnose with CT contrast esophagram; keep NPO, start broad‑spectrum antibiotics and antifungals, and obtain surgical/endoscopic repair with drainage.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CT chest with water‑soluble contrast | Diagnosis | Extraluminal contrast/air | Defines site/extent |
| Esophagram (water‑soluble) | Adjunct | Leak visualization | Avoid barium initially |
| Labs, lactate, ABG | Severity | Sepsis, acidosis | Guide resuscitation |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Piperacillin‑tazobactam (or carbapenem) + antifungal (fluconazole/echinocandin) | Broad antimicrobials | Hours | Polymicrobial and candida risk | Tailor to cultures |
| PPI IV | Acid suppression | Hours | Reduce caustic reflux | Adjunct |
| Analgesia and NPO with NG decompression (selected) | Supportive | Immediate | Reduce contamination | Place under guidance to avoid worsening leak |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- WSES Guidelines for Esophageal Emergencies (perforation) — Link