Spontaneous rupture of the esophagus, with report of five cases.

Abstract

Spontaneous rupture of the esophagus is a rare condition, which until recently carried a grave prognosis. Whereas most cases reported up to 1944 had terminated fatally, there have been, as a result of improved methods of diagnosis and treatment, 16 survivals among 40 cases published during the last six years. Including the 5 examples to be presented here, the world literature contains records of 92 cases, 32 of which have been reported since 1947. So far as we are aware, a single case, that of Aldrich and Anspach (1), is to be found in the radiological literature. Adequate bibliographies are furnished by Barrett (2), Kinsella et al. (29), and Lynch (35). The original description of spontaneous rupture of the esophagus is said by McWeeney (42) to be that of Boerhaave in 1724. The first antemortem diagnosis is credited to Walker in 1924 (56). At present the diagnosis is based upon the patient's history, the clinical findings, and confirmatory roentgenograms. We shall endeavor here to summarize the known facts concerning this condition, with particular emphasis on the roentgen diagnosis. By spontaneous rupture is meant a complete tear involving all layers of the wall of a previously normal esophagus. This excludes incomplete tears and rupture at the site of neoplasm, peptic ulcer, corrosive esophagitis, other forms of esophageal inflammation, aneurysms, perforation from instrumentation, biopsy, or trauma following foreign bodies. Four incomplete tears involving the muscle and mucosal layer at the lower end of the esophagus were found postmortem by Weiss and Mallory (60). Spontaneous rupture of the esophagus occurs usually in middle-aged individuals; it is rare in children though it has been reported (38). Eighty-four per cent of the patients have been males (29). Additional information based on the collected cases is presented in Graph I. Mechanism of Rupture Spontaneous rupture of the esophagus is explained by most authors on the basis of sudden increase in intra-abdominal pressure due to vomiting, retching, or convulsions. The pressure is believed to be transmitted to the esophagus as a consequence of associated pylorospasm and spasm of the cricopharyngeus muscles, resulting in a tear of the lower third. The stomach contents, including air, then dissect upward along the fascial plane of the mediastinum. The air will often invade the neck. The close relationship of the left pleura to the mediastinal portion of the tear in the lower third of the esophagus explains the frequent association of left-sided hydropneumothorax. Surprisingly, no free air has ever been found within the pericardium or abdominal cavity. Mallory (60) and Barrett (2) reported the only cases showing dissection of air retroperitoneally postmortem. The following may aid in explaining rupture of a previously normal esophagus.