Spontaneous Rupture of the Esophagus

Abstract

Spontaneous rupture of the esophagus is due to an increase in intraesophageal pressure greater than the tensile strength of the esophagus. Increased intraesophageal pressure is due to the transmission of increased intraabdominal pressure by the stomach contents through the cardia into the esophagus. Rupture is made more likely by distention of the stomach with food or fluid and by obstruction of the espohagus. Obstruction is usually physiological, produced by the complex anatomical makeup of the esophagus and by incoordination of the complex vomiting reflex. Esophagitis, simple ulcer of the esophagus and esophagomalacia weaken the esophagus and so predispose to rupture. Rupture is seen chiefly in association with vomiting and/or retching, alcoholism and diseases of the central nervous system. The linear tear is in the lower third of the esophagus and leads to the rapid development of mediastinitis and/or hydropneumothorax. The 70 per cent mortality in the first 24 hours is due to the violence of the mediastinitis and pleuritis and to the interference with cardio-respiratory function from mechanical compression. In the usual case, a middle aged male, chronic alcoholic, frequently with chronic dyspepsia, during vomiting and/or retching after recent overindulgence in food or alcohol had sudden onset of chest pain, collapse, respiratory distress, upper abdominal rigidity and later subcutaneous emphysema. In the post craniotomy patients vomiting of blood during recovery from anesthesia occurs; consciousness is lost; and there is progressive restlessness, cyanosis, dyspnea with increasing temperature, pulse and respiratory rates. Definite diagnosis is possible by radiologically observing the passage of radio-opaque media through the rent into the mediastinal and pleural spaces or by aspiration of stomach contents from the pleural space. Mediastinal emphysema, rapidly accumulating hydrothorax, and a retrocardiac air bubble and fluid level are suggestive radiologic findings. In the early cases prompt transpleural repair of the rent is the treatment of choice. In the remainder drainage of the mediastinal and pleural spaces is indicated. The most important of the supportive measures are the decompression of any tension pneumothorax or high pressure mediastinal emphysema, and the use of antibiotic therapy. The various surgical procedures used in the 13 survivors are discussed. Two case reports are given.