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Emergency And Acute Medicine - Esophageal trauma
Basic description
The adult esophagus is approximately 25–30 cm in length and lies in close proximity to the mediastinum, with potential access to the pleural space. It begins at the hypopharynx posterior to the larynx at the level of the cricoid cartilage. On either side are the piriform recesses, which are common sites for foreign body lodgment.
Physiologic narrowing occurs at the cricopharyngeal muscle (upper esophageal sphincter), at the crossover of the left mainstem bronchus and aortic arch, and at the gastroesophageal junction (lower esophageal sphincter). Additional narrowing may occur in areas of disease such as malignancy, webs, or Schatzki rings.
The upper third of the esophagus consists of striated muscle and initiates swallowing. The middle third contains both striated and smooth muscle, and the distal third is composed entirely of smooth muscle. Although relatively fixed, the esophagus may be displaced by adjacent structures such as goiter, enlarged atria, or mediastinal masses.
Etiology
Esophageal trauma may result from external or internal forces.
External mechanisms include penetrating injuries such as stab or missile wounds, direct perforation from foreign bodies, pressure necrosis, chemical or radiation injury, and iatrogenic trauma from instrumentation. Blunt trauma, most commonly from motor vehicle collisions, may also cause injury.
Internal mechanisms include caustic ingestions, infections, medication-induced injury, swallowed foreign bodies, iatrogenic causes, and barotrauma.
Caustic ingestions include alkali substances, which cause liquefaction necrosis and deep tissue penetration, and acids, which cause coagulation necrosis and thermal injury. Chlorine bleach typically causes mucosal edema and superficial erythema.
Infectious causes include viral infections such as CMV, HPV, and HSV, and fungal infections in immunocompromised patients.
Medication-related injury has been reported with agents such as alendronate, doxycycline, NSAIDs, and mycophenolate mofetil.
Swallowed foreign bodies include food bolus impaction, coins, bones, pins, and button batteries. Meat impaction is the most common type in adults, particularly among prisoners, psychiatric patients, intoxicated individuals, and edentulous patients.
Iatrogenic injury accounts for more than half of cases, most commonly due to endoscopy, nasogastric tube placement, or nasotracheal intubation.
Increased intraluminal pressure from vomiting or retching may result in Mallory–Weiss tears, which are mucosal lacerations with bleeding, or Boerhaave syndrome, which is a spontaneous full-thickness rupture of the distal esophagus.
Pediatric considerations
Foreign body ingestion accounts for most cases of esophageal trauma in children, particularly in those aged 18–48 months. Perforations are most often iatrogenic. Caustic ingestions are more common in children younger than five years. Button batteries lodged in the esophagus require urgent removal due to their highly alkaline nature. Single-use laundry detergent packets are an increasingly common hazard.
Diagnosis – signs and symptoms
Common symptoms include dysphagia, odynophagia, chest pain that may be pleuritic and severe, hoarseness, and dyspnea.
Tears or perforations may present with bleeding or hematemesis.
Foreign body ingestion may cause drooling, choking, gagging, vomiting, stridor, wheezing, or inability to tolerate oral intake.
Caustic ingestion may produce oral pain, abdominal pain, vomiting, and drooling.
History
Key historical elements include the type, amount, and timing of ingestions; history of prolonged vomiting; sudden inability to swallow after eating; foreign body sensation; penetrating trauma; or prior cancer therapy.
Physical examination
Findings suggestive of perforation include subcutaneous emphysema at the base of the neck, a Hamman crunch due to mediastinal air, signs of shock, septicemia, or peritonitis.
Penetrating trauma may be associated with injuries to the trachea, neck, chest, or abdomen.
Caustic ingestions may cause airway edema with stridor and visible oral burns.
Essential workup
A high index of suspicion and early diagnosis are critical. Mortality for esophageal perforation is less than 5% if repaired within 24 hours but increases dramatically with delayed diagnosis. Early endoscopy is indicated for caustic ingestions. Chest and lateral neck radiographs are part of the initial evaluation.
Diagnosis tests and interpretation
Laboratory studies may include complete blood count, type and crossmatch for significant bleeding, coagulation studies, electrolytes for prolonged vomiting or retained foreign body, and arterial blood gas analysis in acid ingestions.
Imaging includes chest radiography to assess for pneumomediastinum, pneumothorax, widened mediastinum, or pleural effusion. Lateral cervical spine radiographs may reveal retropharyngeal air or fluid.
Esophagram is useful for suspected perforation, with water-soluble contrast preferred initially. Endoscopy is indicated for suspected perforation, caustic injury, or foreign body removal. CT with dilute oral contrast may aid in identifying perforation and associated complications.
Differential diagnosis
Pulmonary causes include tracheal injury and pneumothorax. Cardiovascular causes include myocardial infarction and aortic dissection. Other esophageal conditions include strictures, neoplasm, Schatzki ring, diverticula, achalasia, esophageal spasm, gastroesophageal reflux, and medication-induced esophagitis.
Treatment
Prehospital care
Chest pain should be presumed cardiac until proven otherwise. Airway protection, suctioning of secretions, intravenous fluids for hypotension or bleeding, and analgesia are indicated. Neutralizing agents and large volumes of oral fluids should be avoided in caustic ingestions.
Initial stabilization and therapy
Airway management and resuscitation are priorities. Establish intravenous access, initiate monitoring, and consider early intubation for penetrating neck or chest injuries.
Emergency department treatment and procedures
Most foreign bodies pass spontaneously, but endoscopic removal is required in a significant minority. Pharmacologic measures such as glucagon, nitroglycerin, or benzodiazepines may be attempted for food impaction. Gastroenterology consultation is indicated if these measures fail.
Caustic ingestions require avoidance of emesis and lavage, cautious dilution with milk, and early endoscopy for prognostication. Corticosteroids are not recommended.
Partial-thickness tears generally heal spontaneously. Full-thickness perforations require surgical consultation, broad-spectrum intravenous antibiotics, and possible operative repair.
Medication
For food impaction, glucagon, nitroglycerin, or diazepam may be used selectively.
For perforation, broad-spectrum intravenous antibiotics such as cefoxitin with gentamicin are indicated. Steroids are not indicated in caustic injury.
Follow-up and disposition
Admission criteria
Indications for admission include caustic ingestion, sharp foreign bodies, airway compromise, penetrating neck or chest trauma, evidence of sepsis or mediastinitis, esophageal perforation, significant bleeding, and inability to tolerate oral intake.
Discharge criteria
Patients may be discharged if bleeding from a partial-thickness tear is self-limited or if a foreign body or food bolus has passed beyond the lower esophageal sphincter without complications.
Clinical pearls and common pitfalls
Time to diagnosis and definitive therapy is the most important predictor of outcome, with intervention within 24 hours significantly reducing mortality. Cervical injuries have better outcomes than thoracic or abdominal injuries. Spontaneous perforation carries the highest mortality, followed by iatrogenic and then traumatic causes.
Basic description
The adult esophagus is approximately 25–30 cm in length and lies in close proximity to the mediastinum, with potential access to the pleural space. It begins at the hypopharynx posterior to the larynx at the level of the cricoid cartilage. On either side are the piriform recesses, which are common sites for foreign body lodgment.
Physiologic narrowing occurs at the cricopharyngeal muscle (upper esophageal sphincter), at the crossover of the left mainstem bronchus and aortic arch, and at the gastroesophageal junction (lower esophageal sphincter). Additional narrowing may occur in areas of disease such as malignancy, webs, or Schatzki rings.
The upper third of the esophagus consists of striated muscle and initiates swallowing. The middle third contains both striated and smooth muscle, and the distal third is composed entirely of smooth muscle. Although relatively fixed, the esophagus may be displaced by adjacent structures such as goiter, enlarged atria, or mediastinal masses.
Etiology
Esophageal trauma may result from external or internal forces.
External mechanisms include penetrating injuries such as stab or missile wounds, direct perforation from foreign bodies, pressure necrosis, chemical or radiation injury, and iatrogenic trauma from instrumentation. Blunt trauma, most commonly from motor vehicle collisions, may also cause injury.
Internal mechanisms include caustic ingestions, infections, medication-induced injury, swallowed foreign bodies, iatrogenic causes, and barotrauma.
Caustic ingestions include alkali substances, which cause liquefaction necrosis and deep tissue penetration, and acids, which cause coagulation necrosis and thermal injury. Chlorine bleach typically causes mucosal edema and superficial erythema.
Infectious causes include viral infections such as CMV, HPV, and HSV, and fungal infections in immunocompromised patients.
Medication-related injury has been reported with agents such as alendronate, doxycycline, NSAIDs, and mycophenolate mofetil.
Swallowed foreign bodies include food bolus impaction, coins, bones, pins, and button batteries. Meat impaction is the most common type in adults, particularly among prisoners, psychiatric patients, intoxicated individuals, and edentulous patients.
Iatrogenic injury accounts for more than half of cases, most commonly due to endoscopy, nasogastric tube placement, or nasotracheal intubation.
Increased intraluminal pressure from vomiting or retching may result in Mallory–Weiss tears, which are mucosal lacerations with bleeding, or Boerhaave syndrome, which is a spontaneous full-thickness rupture of the distal esophagus.
Pediatric considerations
Foreign body ingestion accounts for most cases of esophageal trauma in children, particularly in those aged 18–48 months. Perforations are most often iatrogenic. Caustic ingestions are more common in children younger than five years. Button batteries lodged in the esophagus require urgent removal due to their highly alkaline nature. Single-use laundry detergent packets are an increasingly common hazard.
Diagnosis – signs and symptoms
Common symptoms include dysphagia, odynophagia, chest pain that may be pleuritic and severe, hoarseness, and dyspnea.
Tears or perforations may present with bleeding or hematemesis.
Foreign body ingestion may cause drooling, choking, gagging, vomiting, stridor, wheezing, or inability to tolerate oral intake.
Caustic ingestion may produce oral pain, abdominal pain, vomiting, and drooling.
History
Key historical elements include the type, amount, and timing of ingestions; history of prolonged vomiting; sudden inability to swallow after eating; foreign body sensation; penetrating trauma; or prior cancer therapy.
Physical examination
Findings suggestive of perforation include subcutaneous emphysema at the base of the neck, a Hamman crunch due to mediastinal air, signs of shock, septicemia, or peritonitis.
Penetrating trauma may be associated with injuries to the trachea, neck, chest, or abdomen.
Caustic ingestions may cause airway edema with stridor and visible oral burns.
Essential workup
A high index of suspicion and early diagnosis are critical. Mortality for esophageal perforation is less than 5% if repaired within 24 hours but increases dramatically with delayed diagnosis. Early endoscopy is indicated for caustic ingestions. Chest and lateral neck radiographs are part of the initial evaluation.
Diagnosis tests and interpretation
Laboratory studies may include complete blood count, type and crossmatch for significant bleeding, coagulation studies, electrolytes for prolonged vomiting or retained foreign body, and arterial blood gas analysis in acid ingestions.
Imaging includes chest radiography to assess for pneumomediastinum, pneumothorax, widened mediastinum, or pleural effusion. Lateral cervical spine radiographs may reveal retropharyngeal air or fluid.
Esophagram is useful for suspected perforation, with water-soluble contrast preferred initially. Endoscopy is indicated for suspected perforation, caustic injury, or foreign body removal. CT with dilute oral contrast may aid in identifying perforation and associated complications.
Differential diagnosis
Pulmonary causes include tracheal injury and pneumothorax. Cardiovascular causes include myocardial infarction and aortic dissection. Other esophageal conditions include strictures, neoplasm, Schatzki ring, diverticula, achalasia, esophageal spasm, gastroesophageal reflux, and medication-induced esophagitis.
Treatment
Prehospital care
Chest pain should be presumed cardiac until proven otherwise. Airway protection, suctioning of secretions, intravenous fluids for hypotension or bleeding, and analgesia are indicated. Neutralizing agents and large volumes of oral fluids should be avoided in caustic ingestions.
Initial stabilization and therapy
Airway management and resuscitation are priorities. Establish intravenous access, initiate monitoring, and consider early intubation for penetrating neck or chest injuries.
Emergency department treatment and procedures
Most foreign bodies pass spontaneously, but endoscopic removal is required in a significant minority. Pharmacologic measures such as glucagon, nitroglycerin, or benzodiazepines may be attempted for food impaction. Gastroenterology consultation is indicated if these measures fail.
Caustic ingestions require avoidance of emesis and lavage, cautious dilution with milk, and early endoscopy for prognostication. Corticosteroids are not recommended.
Partial-thickness tears generally heal spontaneously. Full-thickness perforations require surgical consultation, broad-spectrum intravenous antibiotics, and possible operative repair.
Medication
For food impaction, glucagon, nitroglycerin, or diazepam may be used selectively.
For perforation, broad-spectrum intravenous antibiotics such as cefoxitin with gentamicin are indicated. Steroids are not indicated in caustic injury.
Follow-up and disposition
Admission criteria
Indications for admission include caustic ingestion, sharp foreign bodies, airway compromise, penetrating neck or chest trauma, evidence of sepsis or mediastinitis, esophageal perforation, significant bleeding, and inability to tolerate oral intake.
Discharge criteria
Patients may be discharged if bleeding from a partial-thickness tear is self-limited or if a foreign body or food bolus has passed beyond the lower esophageal sphincter without complications.
Clinical pearls and common pitfalls
Time to diagnosis and definitive therapy is the most important predictor of outcome, with intervention within 24 hours significantly reducing mortality. Cervical injuries have better outcomes than thoracic or abdominal injuries. Spontaneous perforation carries the highest mortality, followed by iatrogenic and then traumatic causes.
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