Spontaneous Esophageal Rupture 修改后

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Information about Spontaneous Esophageal Rupture 修改后

Published on May 9, 2009

Author: deepak15

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Description

spontaneous esophageal rupture

SPONTANEOUS ESOPHAGEAL RUPTURE Su HaiYan DEPARTMENT OF EMERGENCY MEDICINE, THE FIRST CLINICAL COLLEGE OF TIANJIN MEDICAL UNIVERSITY

Anatomy General considerations Pathophysiology Diagnosis Treatment Prognosis

Anatomy

General considerations

Pathophysiology

Diagnosis

Treatment

Prognosis

Anatomy of Esophagus

Anatomy of Esophagus

Anatomy of Esophagus The wall of the digestive tube from the mouth to the anus is composed of four basic layers or tunics .

The wall of the digestive tube from the mouth to the anus is composed of four basic layers or tunics .

Anatomy of Esophagus Tunica serosa is the outermost covering of the digestive tube. In most of the digestive tract (stomach and intestines) it consists of a thin layer of loose connective tissue covered by mesothelium (a type of squamous epithelium that lines body cavities); within the peritoneal cavity, this structure is also referred to as visceral peritoneum.

Tunica serosa is the outermost covering of the digestive tube. In most of the digestive tract (stomach and intestines) it consists of a thin layer of loose connective tissue covered by mesothelium (a type of squamous epithelium that lines body cavities); within the peritoneal cavity, this structure is also referred to as visceral peritoneum.

Anatomy of Esophagus In the abdominal cavity, the serosa on each side of the tube fuses together to form a suspensory structure called mesentery, which houses vascular and nervous supplies to the digestive tract and is continuous with the lining of the cavity.

In the abdominal cavity, the serosa on each side of the tube fuses together to form a suspensory structure called mesentery, which houses vascular and nervous supplies to the digestive tract and is continuous with the lining of the cavity.

Anatomy of Esophagus In regions outside of the abdominal cavity where the digestive tube is essentially affixed to adjacent structures via its outer layer of connective tissue (esophagus and rectum), this tunic is referred to as tunica adventitia instead of tunica serosa.

In regions outside of the abdominal cavity where the digestive tube is essentially affixed to adjacent structures via its outer layer of connective tissue (esophagus and rectum), this tunic is referred to as tunica adventitia instead of tunica serosa.

Anatomy of Esophagus Tunica adventitia : irregular dense connective tissue (ct) blends with surrounding ct.

Tunica adventitia : irregular dense connective tissue (ct) blends with surrounding ct.

Anatomy of Esophagus The esophagus extends from the pharynx in the neck through the posterior mediastina and pierces the diaphragm at the level of the tenth thoracic vertebra.

The esophagus extends from the pharynx in the neck through the posterior mediastina and pierces the diaphragm at the level of the tenth thoracic vertebra.

Anatomy of Esophagus Complicated muscular tube Skeletal in upper third; mixed with smooth muscle in middle third; smooth in lower third;

Complicated muscular tube

Skeletal in upper third;

mixed with smooth muscle in middle third;

smooth in lower third;

Anatomy of Esophagus The oesophagus (or gullet) is a complicated muscular tube that carries food and fluid from the throat to the stomach passing through the chest. There is a muscular sphincter (opening) at each end to prevent the stomach contents from refluxing back up the oesophagus.

The oesophagus (or gullet) is a complicated muscular tube that carries food and fluid from the throat to the stomach passing through the chest. There is a muscular sphincter (opening) at each end to prevent the stomach contents from refluxing back up the oesophagus.

Anatomy of Esophagus The lowest of these sphincters is positioned at the junction between the oesophagus and the stomach (level with the diaphragm).

The lowest of these sphincters is positioned at the junction between the oesophagus and the stomach (level with the diaphragm).

Anatomy of Esophagus Three narrow points: Cricoid cartilage Bifurcation of the trachea Diaphragmatic hiatus

Three narrow points:

Cricoid cartilage

Bifurcation of the trachea

Diaphragmatic hiatus

Anatomy of Esophagus Length of esophagus is about 20-24cm. Divide three portions : Cervical Thoracic Abdominal

Length of esophagus is about 20-24cm.

Divide three portions :

Cervical

Thoracic

Abdominal

General Consideration

General Consideration

General Consideration The abbreviation of Spontaneous Esophageal Rupture is SER. SER is also termed as Boerhaave’s syndrome.

The abbreviation of Spontaneous Esophageal Rupture is SER.

SER is also termed as Boerhaave’s syndrome.

General Consideration SER is first reported by Boerhaave. He described the death of a Dutch after he overindulged in wine and subsequently vomited. The autopsy revealed a ruptured esophagus and gastric contents polluted the pleural space.

SER is first reported by Boerhaave.

He described the death of a Dutch after he overindulged in wine and subsequently vomited.

The autopsy revealed a ruptured esophagus and gastric contents polluted the pleural space.

General Consideration The etiology is overindulgent ingestion of food and alcohol and subsequently nausea , vomit. Other causes such as blunt trauma , childbirth,laughing and so on.

The etiology is overindulgent ingestion of food and alcohol and subsequently nausea , vomit.

Other causes such as blunt trauma , childbirth,laughing and so on.

General Consideration It often occurs in middle-aged males. Female and neonatal cases have also been reported. The diagnosis relies on history ,physical examination and laboratory data. Diagnosis and operative treatment at an early stage is crucial to the prognosis.

It often occurs in middle-aged males.

Female and neonatal cases have also been reported.

The diagnosis relies on history ,physical examination and laboratory data.

Diagnosis and operative treatment at an early stage is crucial to the prognosis.

Pathophysiology

Pathophysiology

Pathophysiology Spontaneous rupture may occur just above the diaphragm in the left posterior lateral wall of the esophagus. This intrinsic weakness has been demonstrated in the esophagus of cadavers. Perforations are usually longitudinal (0.6-8.9 cm long), with the left side more commonly affected than the right (90%).

Spontaneous rupture may occur just above the diaphragm in the left posterior lateral wall of the esophagus.

This intrinsic weakness has been demonstrated in the esophagus of cadavers.

Perforations are usually longitudinal (0.6-8.9 cm long), with the left side more commonly affected than the right (90%).

Pathophysiology Vomiting is forcing the contents of the stomach up through the esophagus and out of the mouth.

Vomiting is forcing the contents of the stomach up through the esophagus and out of the mouth.

Pathophysiology Vomiting is a forceful action accomplished by a fierce, downward contraction of the diaphragm. At the same time, the abdominal muscles tighten suddenly against a relaxed upper stomach with an open sphincter. The contents of the stomach are propelled up and out.

Vomiting is a forceful action accomplished by a fierce, downward contraction of the diaphragm. At the same time, the abdominal muscles tighten suddenly against a relaxed upper stomach with an open sphincter. The contents of the stomach are propelled up and out.

Pathophysiology A disorganized vomiting reflex in which the upper esophageal sphincter fails to relax during vomiting leads to increase in esophageal pressure. The pressure of pleural space is lower than the intra-esophageal pressure. When intra-esophageal pressure is increased, the lack of striated muscle and the vertical arrangement of longitudinal muscles in lower esophagus make it weak and amenable to rupture.

A disorganized vomiting reflex in which the upper esophageal sphincter fails to relax during vomiting leads to increase in esophageal pressure. The pressure of pleural space is lower than the intra-esophageal pressure. When intra-esophageal pressure is increased, the lack of striated muscle and the vertical arrangement of longitudinal muscles in lower esophagus make it weak and amenable to rupture.

Pathophysiology Other areas have rarely been reported to rupture and create an emetic injury like that of Boehaave , s syndrome: Cervical Midthoracic Infradiaphragmatic sites

Other areas have rarely been reported to rupture and create an emetic injury like that of Boehaave , s syndrome:

Cervical

Midthoracic

Infradiaphragmatic sites

Pathophysiology More than 80% of these injuries occur in middle-aged males following the overindulgent ingestion of food and alcohol.

More than 80% of these injuries occur in middle-aged males following the overindulgent ingestion of food and alcohol.

Pathophysiology A tear similar to that seen in cases of Boehaave , s syndrome requires a force of 3 to 6 lb/in ,which may be generated in vivo by gastric pressure caused by emesis.

A tear similar to that seen in cases of Boehaave , s syndrome requires a force of 3 to 6 lb/in ,which may be generated in vivo by gastric pressure caused by emesis.

Pathophysiology Increasing intraabdominal pressure cause this injury: Blunt trauma Seizures Childbirth Laughing Straining at stool Heavy lifting

Increasing intraabdominal pressure cause this injury:

Blunt trauma

Seizures

Childbirth

Laughing

Straining at stool

Heavy lifting

Diagnosis

Diagnosis

Diagnosis History Physical examination Laboratory

History

Physical examination

Laboratory

Diagnosis 1.Symptoms The most reliable symptom of an esophageal injury is pain localized along the course of the esophagus.The pain usually is pleuritic. It may be exacerbated by swallowing and by neck flexion. It may be located in the epigastrium, substernal area, or the back.

1.Symptoms

The most reliable symptom of an esophageal injury is pain localized along the course of the esophagus.The pain usually is pleuritic. It may be exacerbated by swallowing and by neck flexion. It may be located in the epigastrium, substernal area, or the back.

Diagnosis As the process advances, the pain worsens over time and moves from the abdomen into the chest, the patient may experience dyspnea and shock.

As the process advances, the pain worsens over time and moves from the abdomen into the chest, the patient may experience dyspnea and shock.

Diagnosis 2.Signs The early physical signs of esophageal perforation are sparse. As air and caustic contaminated material move through the esophageal tear into the mediastinum and pleural space, the true gravity of the condition becomes manifest. This mediastinal air may surround the heart and produce a systolic crunching.

2.Signs

The early physical signs of esophageal perforation are sparse.

As air and caustic contaminated material move through the esophageal tear into the mediastinum and pleural space, the true gravity of the condition becomes manifest. This mediastinal air may surround the heart and produce a systolic crunching.

Diagnosis When air and fluid move into the pleural space, it may result in the signs of hydropneumothorax and empyema. When air travels into subcutaneous tissues, subcutaneous emphysema may become evident. This classic sign is present in only about 60% of these patients.

When air and fluid move into the pleural space, it may result in the signs of hydropneumothorax and empyema.

When air travels into subcutaneous tissues, subcutaneous emphysema may become evident. This classic sign is present in only about 60% of these patients.

Diagnosis As the infective and inflammatory process advances, the patients may manifest the signs of cardiopulmonary collapse and sepsis with fever, cyanosis, hypotention, anuria,and eventually death.

As the infective and inflammatory process advances, the patients may manifest the signs of cardiopulmonary collapse and sepsis with fever, cyanosis, hypotention, anuria,and eventually death.

Diagnosis 3. Laboratory Examination 3.1 The pleural effusion liquid examination Very low PH High level of salivary amylase

3. Laboratory Examination

3.1 The pleural effusion liquid examination

Very low PH

High level of salivary amylase

Diagnosis 3.2 Radiographic Examination Mediastinal air with or without subcutaneous emphysema Left-side pleural effusion Pneumothorax Widened mediastinum

3.2 Radiographic Examination

Mediastinal air with or without subcutaneous emphysema

Left-side pleural effusion

Pneumothorax

Widened mediastinum

Diagnosis At an early stage the radiographic examination may be normal. 1~2 hours later it may take on mediastinal air with or without subcutaneous emphysema. Several hours later it may take on widened mediastinum. Left-side pleural effusion ,Pneumothorax And hydropneumothorax may also occur.

Diagnosis Esophagram is a useful procedure in diagnosing esophageal injuries. The esophagus is barium-filled. Barium flow from esophagus through the perforation.

Esophagram is a useful procedure in diagnosing esophageal injuries.

The esophagus is barium-filled. Barium flow from esophagus through the perforation.

Diagnosis It is, however, up to 25% of these studies have false-negative results. It is generally recommended that the initial study employ a water-soluble agent, and then if no gross leak is demonstrated, a barium study may be undertaken to better define the mucosal detail.

It is, however, up to 25% of these studies have false-negative results. It is generally recommended that the initial study employ a water-soluble agent, and then if no gross leak is demonstrated, a barium study may be undertaken to better define the mucosal detail.

Diagnosis 3.3 Endoscopy Examination: Endoscopy is not an infallible aid in establishing the presence or absence of an esophageal perforation.

3.3 Endoscopy Examination:

Endoscopy is not an infallible aid in establishing the presence or absence of an esophageal perforation.

Diagnosis

This 36-year-old man presented with hematemesis after an alcoholic binge. Endoscopy shows oozing blood from a base of a clot overlying a Mallory-Weiss tear (arrow).  

This 36-year-old man presented with hematemesis after an alcoholic binge. Endoscopy shows oozing blood from a base of a clot overlying a Mallory-Weiss tear (arrow).  

Posteroanterior chest radiograph shows a right-sided hydropneumothorax after an esophageal rupture.  

Posteroanterior chest radiograph shows a right-sided hydropneumothorax after an esophageal rupture.  

Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows a false tract emanating from the esophagus (arrow).

Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows a false tract emanating from the esophagus (arrow).

Diagnosis The diagnosis of any esophageal perforation rests primarily on the clinician , s high index of suspicion for this injury. In patients with the classic Boehaave , s syndrome with overindulgence and emesis followed by severe chest pain, subcutaneous emphysema, and cardiopulmonary collapse, the diagnosis is readily confirmed.

The diagnosis of any esophageal perforation rests primarily on the clinician , s high index of suspicion for this injury. In patients with the classic Boehaave , s syndrome with overindulgence and emesis followed by severe chest pain, subcutaneous emphysema, and cardiopulmonary collapse, the diagnosis is readily confirmed.

Diagnosis Up to one third of cases of a perforated esophagus, however, are atypical. About 25% of patients with Boehaave , s syndrome have no history of emesis. In almost 50% of those who do vomit, the relationship between the vomiting and the onset of pain does not suggest an emetic injury.

Up to one third of cases of a perforated esophagus, however, are atypical.

About 25% of patients with Boehaave , s syndrome have no history of emesis.

In almost 50% of those who do vomit, the relationship between the vomiting and the onset of pain does not suggest an emetic injury.

Diagnosis Only a careful history and physical examination supplemented with appropriate laboratory and x-ray studies enable the clinician to diagnose a subtle case at an early stage.

Only a careful history and physical examination supplemented with appropriate laboratory and x-ray studies enable the clinician to diagnose a subtle case at an early stage.

Differential diagnosis

Differential diagnosis

Different diagnosis Pulmonary embolus Acute myocardial infarction (AMI) Pancreatitis Perforated peptic ulcer Cholecystitis Aortic aneurysm

Pulmonary embolus

Acute myocardial infarction (AMI)

Pancreatitis

Perforated peptic ulcer

Cholecystitis

Aortic aneurysm

Different diagnosis 1. Pulmonary embolus: Pulmonary embolism can be defined as the occlusion of one or more vessels in the pulmonary arterial tree by matter from a source extrinsic to the lung. The process is almost invariably acute but may on occasion be chronic. The diagnosis should be based on the presence risk factors, symptoms,chest radiograph, ventilation/perfusion lung scanning, pulmonary angiography etc.

1. Pulmonary embolus:

Pulmonary embolism can be defined as the occlusion of one or more vessels in the pulmonary arterial tree by matter from a source extrinsic to the lung. The process is almost invariably acute but may on occasion be chronic. The diagnosis should be based on the presence risk factors, symptoms,chest radiograph, ventilation/perfusion lung scanning, pulmonary angiography etc.

Different diagnosis 2. Acute myocardial infarction (AMI) : AMI results from prolonged myocardial ischemia. The diagnosis depends on history, changes of ECG, and characteristic cardiac enzymes.

2. Acute myocardial infarction (AMI) :

AMI results from prolonged myocardial ischemia. The diagnosis depends on history, changes of ECG, and characteristic cardiac enzymes.

Different diagnosis 3. Pancreatitis: Acute pancreatitis is an acute inflammatory disorder with abdominal pain associated with elevations of pancreatic enzymes, and it is a common disorder that may vary in severity from mild to fulminant.

3. Pancreatitis:

Acute pancreatitis is an acute inflammatory disorder with abdominal pain associated with elevations of pancreatic enzymes, and it is a common disorder that may vary in severity from mild to fulminant.

Treatment

Treatment

Treatment 1. Non-operative treatment: Given nothing by mouth; Broad-spectrum intravenous antibiotics. Volume replacement and other support as needed; A nasogastric tube should be carefully passed to decompress the stomach. Patients should be given parenteral nutrition (PN) for at least 10d while they are given nothing by mouth.

1. Non-operative treatment:

Given nothing by mouth;

Broad-spectrum intravenous antibiotics.

Volume replacement and other support as needed;

A nasogastric tube should be carefully passed to decompress the stomach.

Patients should be given parenteral nutrition (PN) for at least 10d while they are given nothing by mouth.

Treatment 2. Operative treatment: If the patient’s condition fails to improve or deteriorates within 24h of initiation of non-operative treatment, strong consideration should be given to operative management.

2. Operative treatment:

If the patient’s condition fails to improve or deteriorates within 24h of initiation of non-operative treatment, strong consideration should be given to operative management.

Prognosis

Prognosis

Prognosis Predicting a poor prognosis: Poor general medical consideration, most notably the presence of esophageal cancer; Spontaneous perforation; Greater than 24h delay prior to diagnosis and initiation of treatment.

Predicting a poor prognosis:

Poor general medical consideration, most notably the presence of esophageal cancer;

Spontaneous perforation;

Greater than 24h delay prior to diagnosis and initiation of treatment.

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