The Causes, Signs, and Symptoms of a Perforated Esophagus

The esophagus is the tube of smooth muscle that moves food from the back of the throat (pharynx) to the stomach. A perforated esophagus is an esophagus that has ruptured or torn and now has a hole in it. This results in the leaking of food and sometimes even digestive fluid into the chest, and it can result in a serious infection. The perforated esophagus may be more common in men than in women and often occurs after binge eating. It is also more common for individuals who have an underlying disease of the esophagus including GERD or hiatal hernia.

Signs and symptoms of a perforated esophagus include:

• Difficulty swallowing
• Vomiting or retching followed by severe chest pain
• Difficulty breathing
• Difficulty speaking
• Neck pain, shoulder pain, upper or lower back pain. Discomfort may increase when lying down flat
• Rapid breathing and heart rate
• Fever
• Bloody vomit (rare)
• Subcutaneous emphysema (gas or air underneath the skin) especially in the neck and chest

Perforation of the esophagus is fairly uncommon but can be quite serious, even deadly. Prompt treatment provides the best outcomes but unfortunately, treatment is often delayed due to misdiagnosis. A perforated esophagus is often confused with other conditions such as a heart attack, perforated peptic ulcers or acute pancreatitis.

Causes of a perforated esophagus include:

• Procedures such as an endoscopy (EGD). Especially when dilation of the esophagus or esophageal strictures is involved, during sclerotherapy, or variceal ligation. Other procedures including placement of an endotracheal tube, nasogastric tube or Blakemore tube (rare). Individuals who are older than 65 years are also at increased risk.
• Ingestion of hazardous chemicals such as cleaners or disc batteries.
• Ingestion of a foreign object (pills and coins are common culprits).
• Injuries such as gunshot or stab wounds, up to 10 percent of cases.
• Boerhaave syndrome is a very rare condition in which the esophagus spontaneously ruptures usually as the result of violent vomiting or retching. Most common in individuals ages 40-60 years. Accounts for about 15 percent of cases.
• Chronic esophageal conditions that cause thinning of the esophageal wall.
• A complication of surgery including cardiothoracic surgery or fundoplication (rare).
• Tumors

Complications of a perforated esophagus may include pneumonia, mediastinitis, sepsis, empyema, and adult respiratory distress syndrome (ARDS). The condition often requires surgery and antibiotics. A mild perforation in the upper portion of the esophagus may heal without surgery, but patients are often instructed not to eat or drink and may require nutrition from a feeding tube or IV until the esophagus heals. In some cases, an endoscopic procedure to place stents or clips can be used in this situation.