Esophageal Trauma is a topic covered in the 5-Minute Emergency Consult.

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Basics

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 3rd of esophagus is striated muscle:
    • Initiates swallowing
  • Middle portion is 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

Mechanism
  • 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
      • Alendronate, Doxycycline, NSAIDs
      • Mycophenolate mofetil
      • 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 (55%):
    • Perforation secondary to instrumentation, endoscopy most common cause
    • Nasotracheal intubation/nasogastric (NG) tube most common cause in emergency department
  • 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

Pediatric Considerations
  • 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

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Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Esophageal Trauma ID - 307329 Y1 - 2016 PB - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307329/all/Esophageal_Trauma ER -