Esophageal Perforation Associated With Barotrauma

Abstract

Esophageal perforation continues to present a diagnostic and therapeutic challenge despite decades of clinical experience and innovation in surgical technique. The incidence of esophageal perforation has increased with the advancement of invasive diagnostic technology and the etiology has changed from spontaneous or traumatic to mostly iatrogenic. The incidence of esophageal perforation following external blast injuries is quite rare, 0.004-0.01%. We describe a case of barotrarumatic esophageal perforation. A 30-year-old male presented to hospital following a high pressure air hose injury of mid face and mouth. The patient complained of immediate shortness of breath, neck and facial pain was intubated on scene for stridor and shortness of breath. Examination was significant for facial swelling, subcutaneous emphysema to his neck and upper chest. Computed Tomography(CT) scan of chest was significant for bilateral pneumothorax, pneumomediastinum and subcutaneous emphysema. B/L chest tube were placed followed by resolution of pneumothorax. He was admitted to intensive care unit with preliminary diagnosis of bilateral traumatic pneumothorax and lung contusion. Due to concern for digestive tract injury urgent esophagoscopy (EGD) was performed which didn't reveal any perforation or tears. Further course was complicated by development of empyema and mediastinitis. Repeat CT scan with oral and IV contrast demonstrated a large 4 cm tear in the mid esophagus. The medical therapy included parenteral nutritional support and broad spectrum antibiotics. The patient refused surgical treatment and an esophageal stent was placed under endoscopic and fluoroscopic guidance. Despite the stent placement he developed persistent leak. Perforation was successfully treated by surgical repair with muscle flap followed by interval removal of the stent post surgery. Common clinical manifestations of esophageal perforation include chest pain, dysphagia, dyspnea, subcutaneous emphysema, epigastric pain, fever, tachycardia, and tachypnea. Any combination of these signs and symptoms following instrumentation of the esophagus or respiratory tract implies perforation until proven otherwise. In spontaneous perforations like blast injuries the left border of lower third of thoracic esophagus is involved in 80% of the cases, 3-6cm on average. GI Contrast enhanced CT is the initial choice of diagnosis as its sensitivity ( 92-100% ) is better than esogastroduodenal follow through.