Description on esophagus and its injuries

1. oesophagus injuries
perforation
Sumit kamma
Roll no-99

2. Introduction
● Any oesophageal perforations , also known as a ruptured or torn oesophagus
means a hole or tear in the oesophagus.
● The tube that carries food and liquid from the mouth to the stomach.
● This is a serious condition that require immediate medical attention and open
surgical repair.

3. ● It is associated with high morbidity and mortality rates
● It is an emergency and prompt treatment Should be instituted because
delayed diagnosis and treatment are associated with a marked Increase in
mortality rate

4. Aetiology
1. Iatrogenic perforation
2. Spontaneous perforation
3. Blunt trauma
4. Corrosive Ingestion
5. Foreign body ingestion

5. Iatrogenic perforation
● Most common
● Commonly in upper ⅓ (pharyngoesophageal junction
● Increased risk:endoscopy procedures such as EMR/ ESD/POEM
● Features:chest pain / abdominal pain post endoscopy
● IOC:
stable Patient: CECT
Unstable Patient: contrast study

6. Management:
● In stable patients/Small perforation/Cervical esophagus
● Conservative management
1. Npo( nil per oral)
2. Iv fulid
3. Iv antibiotics
4. Pain killer's

7. In unstable patients/large Perforation/ Thoracic esophagus
● Perfer surgery
Thoracotomy
+
Repair esophagus
+
Chest tube insert

8. Spontaneous perforation
● Aka Boerhaave’s syndrome
● results from a sudden Increase in oesophageal pressure against a closed
glottis from vomiting ( MC in alcoholics)
● Mc site : left posterolateral wall of lower ⅓ of

9. ● Clinical Features:Mackler’s triad
Chest pain + Retching+subcutaneous emphysema
● Heart auscultation: Hamman’s crunch due to pneumomediastinum
● Investigation of choice:
Stable patients: CECT
Unstable Patients: contrast study

10. X- ray:
● Pneumomediastenum sign:spinnaker sign

11. ● Left side pleural effusion ( as perforation is common in left)

12. Management of Boerhaave’s syndrome
● Patients present early ( within 12 hr)
● With minimal Sepsis &
● Stable Patient
Thoracotomy
+
Repair the tear
+
Chest Tube

13. ● Patient present late
● Sepsis
● Unstable Patient
Emergency Thoracotomy done
● Neck esophagostomy( proximal end connected to neck)
● Gastrotomy for nutrition:
After 10 to 12 wks anastomosis 2end

14. Blunt trauma
● Blunt external trauma rarely causes oesophageal perforations .
● Perforations from penetrating trauma is rare as the Oesophagus is deep
seated organ.

15. Foreign body perforations
● Foreign body ingestion, especially with sharp objects, may perforated
oesophagus.
● Clinical Features: dysphagia (early) ,pain,breathing difficulty
● Ioc : x- ray , AP view- FB lies in coronal plane
Lateral view- FB is posterior

17. ● FB in trachea is differentiate by clinical Features as well as by x-ray
● Clinical Features: stridor ,breathing difficulty
● On x-ray, AP view - FB lies in sagittal plane
Lateral view- FB is anterior

19. Management
● FB in esophagus
● Asymptomatic patient
● FB beyond C6 level
Observation
Serial x- ray ( to check for distal migration of FB)
Check stools for FB

20. ● Patient is symptomatic
● FB impacted at C6 level
● FB is button batteries
Endoscopic removal prefer
● Button batteries can disintegrate ,which can perforated the oesophagus

21. Corrosive esophageal perforation
● Corrosive Ingestion can also lead to transmutation necrosis and disruption of
the oesophageal wall.
● Corrosive are two type - Acid & Alkali
● Alkali penetration in oesophagus is deep than Acid
● Alkali penetrate through Saponification mechanism
● Acid penetrate through Coagulation mechanism
● Alkali lesser damage to stomach
● Acid more damage to stomach by pylorospasm

22. ● Most caustic ingestion Occur in children accidentally, in adults with suicidal
intent.
● It is mild injury, but also is potentially lethal.
● The severity Of injury depends on the type, pH, quantity and duration of
exposure.
● Clinical Features: pain in neck,throat, chest.
● Drooling of saliva,dysphagia can be present
● Hoarseness of voice is an important sign as it may signify laryngeal injury
and potential airway obstruction.
● Diagnosis by injurious agent pH testing.

23. Initial management:
● Resuscitation with iv fluid
● Pain management
● Nasogastric tubes should not be inverted blindly ( can causes perforation)
● No use of prophylactic antibiotics
● No role of gastric lavage

24. Management after patient stabilised
● Early skilled endoscopy must done
● No role of steroids
● Definite Treatment: long term management of stricture ,as it is complication
● A nasogastric / duodenal tube can be placed with endoscopy guidance.
● Use for alimentary nutritional support.
● Most caustic injury managed Conservatively with supportive measures.

27. Management of stricture:-
1. Regular dilation
2. Long complete stricture: Oesophagectomy
Normally when Oesophagus is removed, stomach used as replacement.
But in corrosive/ caustic injury, colon or jejunum used as replacement

29. Summary:oesophageal perforations
● Potentially lethal condition due to sepsis
● Surgical emphysema, chest pain and vomiting constitute the classic triad of
Boerhaave’s syndrome
● Treatment aims at adequate drainage,closer of perforation site if possible and
supportive measure
● Delayed diagnosis and management lead to high morbidity and mortality
rates.

30. Refrance:-
● Bailey & love’s short practice of surgery

31. Thank you