This document discusses esophageal trauma, including: 1) Esophageal injuries can occur from trauma or medical procedures and allow stomach contents to leak into surrounding tissues, potentially causing infection. 2) The esophagus has four layers and passes behind the heart and lungs before connecting to the stomach. Injuries can occur in the cervical, thoracic, or abdominal sections. 3) Symptoms of esophageal trauma include chest pain, vomiting, difficulty swallowing, and shortness of breath. Diagnosis involves imaging tests and ruling out other potential causes of symptoms. Treatment may involve antibiotics, draining fluids, and surgery depending on the severity of the injury.

1. ESOPHAGEAL
TRAUMA
S U B M I T T E D B Y
J E S N A J O Y
G R O U P : 7
F A C I L I T Y O F M E D I C I N E : - 5 T H Y E A R 2 N D
S E M E S T E R

2. INTRODUCTION
• Esophageal injury (EI) is a rare but challenging clinical finding in the setting of trauma.
• In this injuries/perforations are transmural disruptions of the esophagus that
subsequently lead to leakage of intraluminal contents into the surrounding
mediastinum.
• This causes local inflammation, systemic inflammatory response, and eventually the
development of sepsis that results in significant morbidity and mortality.
• The site of perforation varies depending upon the cause. Instrumental perforation is
common in the pharynx or distal esophagus.

3. ANATOMY
• The esophagus is a fibromuscular tube, about 25 centimeters long in adult.
• which travels behind the trachea and heart, passes through the diaphragm and
empties into the uppermost region of the stomach.
• The esophagus is divided into three main anatomical regions: cervical, thoracic, and
intra-abdominal esophagus.
• During swallowing, the epiglottis tilts backwards to prevent food from going down the
larynx and lungs.
• It consists of the following four layers:External fibrous layer ,Intermediate muscular
layer, Intermediate submucosal layer ,Internal mucosal layer

5. EPIDEMIOLOGY
• The frequency of esophageal injury is 3 in 100,000 in the United States. The distribution
by location is as. Cervical - 27% , Intrathoracic - 54% ,Intra-abdominal - 19%.
• Penetrating EI is more common than blunt EI, with a corresponding ratio of approximately
10-to-1
• The most common etiologies in the United States are gunshot wounds (about 75%) and
stab wounds (about 15%).
• The morbidity and mortality of esophageal injuries are usually determined by a
combination of temporal, patient, and injury severity factors.
• Traumatic esophageal injuries often present a diagnostic challenge, especially because of
the potential for damage to surrounding tissues and concurrent contamination.
• Consequently, the trauma surgeon must be aware of the various mechanisms of EI,
employ a high index of clinical suspicion, and act in a timely manner when an injury is
suspected.

6. ETIOLOGY
• Esophagus rupture is usually iatrogenic , the result of endoscopic procedures .Biggest
risk during endoscopic procedures .(diagnostic endoscopy, endoscopic biopsy,
variceal sclerotherapy, endoscopic stent placement, nasogastric tube placement , mini
tracheotomy )
• Foreign bodies (bones, denatures , button barriers )
• Trauma (blunt ,penetrating, iatrogenic)
• Spontaneous Boerhaave syndrome

7. • Non esophageal surgery ( Mediastinal and cervical-thyroid, lung, spine and mediastinal
Tumours
• Malignancy of esophagus, , lung and other mediastinal structures
• Infective causes (candida, herpes, syphilis ,tuberculosis)
• Severe reflex and Mallory-Weiss tear
• Caustic agents (alkali, acid )

8. PATHOPHYSIOLOGY
• Because the esophagus lacks a serosal layer, it is more vulnerable to rupture or
perforation.
• Once a perforation occurs, retained gastric contents, saliva, bile, and other substances
may enter the mediastinum, resulting in Mediastinitis.
• The degree of mediastinal contamination and the location of the tear determine the
clinical presentation. Within a few hours, a polymicrobial bacterial invasion occurs,
which can lead to sepsis and eventually , death.
• The mediastinal pleura often ruptures, and gastric fluid is drawn into the pleural space
by the negative intrathoracic pressure. Even if the mediastinal pleura is not violated, a
sympathetic pleural effusion often occurs .
• Direct tissue damage due to acidic enteric contents combined with bacterial
contamination of the mediastinal pleura means that therapeutic level of systemic
antibiotics may not be achieved their target site.

9. CLINICAL FEATURES
 TYPICAL SYMPTOMS
• Pain of variable location, commonly in the lower anterior chest or upper abdomen
• Vomiting
• Subcutaneous emphysema
• Neck pain
• Dysphagia
• Dyspnea
• Hematemesis
• Melena
• Back pain

10. ATYPICAL SYMPTOMS
• Shoulder pain
• Facial swelling
• Hoarseness
• Dysphonia

11. PHYSICAL EXAMINATION
• Fever ,Crepitus, Tachycardia, Tachypnea, Cyanosis ,Dyspnea, Upper abdominal
rigidity, Shock, Local tenderness
• On inspection subcutaneous emphysema may be obvious,with neck and chest wall
swelling , giving a characteristic cracking sensation palpation as trapped air moved
within the tissue planes.
• Percussion of the chest wall will be resonant if a pneumothorax is present, or indeed
dull if there is lung atelectasis.
• If presence of pneumomediastinum cracking sound upon auscultation and Makclers
triad ,consist of thoracic pain ,vomiting and subcutaneous emphysema.

12. COMPLICATIONS
Mediastinitis
 Intrathoracic abscess
 Sepsis
Respiratory failure
Shock

13. DIAGNOSIS
History and clinical examination
Laboratory-FHG
Radiography plain
• Neck X-ray lateral view
• Chest X-ray posterioanterior view
• Abdominal X-ray
Radiology contrast
• Gastrografic study (water soluble contrast)
• The barium swallow study
• CT scan of chest and abdomen with contrast
MRI chest and abdomen
Ventilation perfusion scan
 ECG

15. DIFFERENTIAL DIAGNOSIS
• Chronic gastric, and duodenal ulcer diseases
• Mayocardial infractions
• Acute pancreatitis
• Dissecting aortic aneurysms
• Pneumonia
• Pneumothorax

16. MANAGEMENT
• Medical Therapy
• Admission to a medical or surgical intensive care unit (ICU)
• Nothing by mouth
• Parenteral nutritional support Nasogastric suction - This should be maintained until there is evid
indicate that the esophageal perforation has healed, is smaller, or is unchanged.
• Along with parenteral nutrition PPI also given
• Broad-spectrum antibiotics - No randomized clinical trials exist for antibiotics and esophageal
perforation; however, empiric coverage for anaerobic and both gram-negative and gram-positiv
aerobes should be initiated when the initial diagnosis is suspected.
• Narcotic analgesics

17. • Non operative treatment
• Recent iatrogenic perforation or late iatrogenic or postemetic esophageal
perforation
• Intrathoracic perforation
• Absence of sepsis
• Medical contraindications for surgery (eg, severe emphysema or severe
coronary artery disease)
• Isolation of the leak within the mediastinum or between the mediastinum and
visceral pleura (no extravasation of contrast into adjacent body cavities)
• No malignancy, obstruction, or stricture in the region of the perforation
• Minimal symptoms
• Drainage of perforation into the esophagus

18. • Surgical therapy
• Tube thoracostomy ( drainage with a chest tube or operative drainage alone)
• Primary repair
• Primary repair with reinforcement with pleura, intercostal muscle, diaphragm, pericardial fat,
pleural flap
• Diversion
• Diversion and exclusion
• Esophageal resection
• Thoracoscopic repair
• Esophageal stenting
• Endoscopic placement of fibrin sealant
• Endoscopic suture ligation
• Endoluminal negative-pressure therapy

20. • https://www.ncbi.nlm.nih.gov/books/NBK470161/#article-21348.s1
• https://emedicine.medscape.com/article/425410-treatment#showall
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219576/#!po=31.2500
REFERENCE

21. THANK YOU