Esophageal Trauma

Description

• Adult esophagus is ∼25–30 cm in length in close proximity to mediastinum with access to pleural space
• It begins at hypopharynx posterior to larynx at level of cricoid cartilage
• On either side of this slit are piriform recesses:
  • May be site for foreign body to lodge
• Sites of esophageal narrowing:
  • Cricopharyngeal muscle (upper esophageal sphincter)
  • Crossover of left main stem bronchus and aortic arch
  • Gastroesophageal junction (lower esophageal sphincter)
  • Areas of disease (cancer, webs, or Schatzki ring)
• Upper third of esophagus is striated muscle:
  • Initiates swallowing
• Middle portion is a mixture of striated and smooth
• Distal portion is smooth muscle
• It is a fixed structure, but can become displaced by other organs:
  • Goiter
  • Enlarged atria
  • Mediastinal masses

Etiology

• External forces or agents (30%):
  • Penetrating: Leading to tears:
    • Stab wounds
    • Missile wounds
  • Perforation:
    • Foreign bodies via direct penetration
    • Pressure necrosis
    • Chemical necrosis
    • Radiation necrosis from selective tissue ablation
    • Instrumentation
  • Blunt: Motor vehicle accident
• Internal forces or agents:
  • Caustic ingestions/burns:
    • Acid pH <2, alkali pH >12 accidental or intentional
    • Alkali (42%): Liquefaction necrosis causing burns, airway edema or compromise, perforation, chronic stricture, and cancer
    • Acid (32%): Coagulation necrosis, thermal injury, and dehydration causing perforation, ulceration, and infection, more likely to perforate than alkali
    • Chlorine bleach (26%): Mucosal edema, superficial erythema
  • Infections:
    • Viruses (CMV, HPV, and HSV) or fungi in immunocompromised patients
  • Drugs:
    • Less common but case series reported alendronic acid, Doxycycline, NSAIDs, mycophenolic acid, may cause esophageal erosion or esophagitis
  • Swallowed agents:
    • Food bolus impaction
    • Coins, bones, buttons, marbles, pins, button batteries
  • Most common type is meat
• In adults: Prisoners, psychiatric patients, intoxicated patients, or edentulous patients
• Iatrogenic (59%):
  • Perforation secondary to instrumentation, endoscopy most common cause
  • Nasotracheal intubation/nasogastric (NG) tube most common cause in ED
• Increased gastric pressure (15%):
  • Large pressure differences between thorax and intra-abdominal cavity:
    • May lead to lacerations or perforation
  • Mallory–Weiss syndrome:
    • Longitudinal tears in distal esophageal mucosa with bleeding
  • Boerhaave syndrome:
    • Spontaneous esophageal rupture
    • Full-thickness rupture of distal esophagus
    • Classically after alcohol or large meals and vomiting

• Foreign bodies:
  • Accounts for 75–80% of swallowed foreign bodies:
  • Typically in infants ages 18–48 mo
  • Entrapment usually at upper esophageal sphincter
  • Perforations
  • Commonly iatrogenic with NG insertion, stricture dilation, and endotracheal intubation
• Caustic ingestions:
  • More common in children <5 yr
  • Button batteries highly alkaline and need removal if lodged in esophagus within 4–6 hr
  • Packets of single-use laundry/dishwasher detergents are prevalent with AAPCC issuing safety warning