Makindo Medical Notes.com

Related Subjects: |Assessing Chest Pain |Achalasia |Oesophageal Carcinoma |Diffuse Oesophageal spasm |Diffuse Oesophageal Perforation - Rupture |Gastro-Oesophageal Reflux |Barrett's oesophagus

Mackler's triad (vomiting, chest pain and surgical emphysema) is classical but absent in almost half the cases. The chest x-ray (CXR) may reveal surgical emphysema and a gastrograffin swallow is diagnostic. A CT scan should be performed if a gastrograffin swallow is not possible or negative.

About

• Perforation leads to possible mediastinitis and surgical emphysema
• Gastric contents enter mediastinum and surrounding structures
• Prompt diagnosis and treatment required

Aetiology

• Perforation due to endoscopic procedure such as stricture dilatation is the commonest cause
• A mucosal tear from forceful vomiting Boerhaave's syndrome usually in the left posterolateral wall of the lower third of the oesophagus
• A malignant perforation, Trauma/Chemical e.g. swallowing sharp or corrosive objects

Clinical

• Fever and Malaise and Vomiting
• A history of forceful vomiting or procedure
• Chest or back discomfort and pain
• Subcutaneous Surgical emphysema
• Crackling sounds audible on cardiac auscultation

Investigations

• Chest X-ray: May show pneumomediastinum (air in the mediastinum), pleural effusion, or pneumothorax. Left sided pleural effusion (low pH and high amylase and purulent with food matter) and empyema
• Gastrograffin (water-soluble) Oesophagragraphy shows a leak but may be falsely negative. Imaging can highlight the site of the perforation.
• OGD should be avoided or done with expert advice as air insufflation can worsen any tear and leak
• Contrast enhanced CT may be useful. Provides detailed images and can identify air or fluid collections in the mediastinum or surrounding tissues.

Complications

• Mediastinitis, Multiorgan failure, Surgical emphysema
• Pleural effusion/empyema, Death
• Adult respiratory distress syndrome, Septicaemic shock

Management

• Usually ITU with access to cardiothoracic input for a surgical assessment
• ABC's IV access, Fluid replacement, Oxygen. May need TPN.
• Broad-spectrum intravenous antibiotics - cover anaerobes and aerobic gram-negative and positive
• Nil by mouth. Take advice on NG tube if vomiting gastric contents
• Liaise with cardiothoracic surgeons: a more conservative approach is more in favour nowadays at least initially
• May be a role for endoscopy and stenting.
• Management depends on cause and underlying pathologies e.g. oesophageal tumour