What are the causes of an esophageal perforation?

From the Guidelines

Esophageal perforation is a serious medical condition that can be caused by various factors, including iatrogenic causes such as endoscopy, dilation, or surgery, which account for approximately 60% of cases 1.

Causes of Esophageal Perforation

• Iatrogenic causes: endoscopy, dilation, or surgery, which account for approximately 60% of cases 1
• Spontaneous rupture: often due to forceful vomiting or retching, which accounts for around 15% of cases 1
• Trauma: including penetrating injuries or blunt trauma to the chest or abdomen
• Foreign body ingestion: such as bones or other sharp objects
• Caustic ingestion: including acids or alkalis
• Tumors: including esophageal cancer or metastatic disease
• Infections: such as esophagitis or abscesses
• Inflammatory conditions: such as esophageal ulcers or Crohn's disease
• Medications: including bisphosphonates, such as alendronate, and certain antibiotics, such as doxycycline, which can cause esophageal irritation or ulceration

Specific Causes and Risks

The risk of perforation is higher with certain procedures, such as esophageal dilation for achalasia, which has a reported risk of 0.4-14% 1, and endoscopic mucosal resection (EMR), which has a reported risk of 0-3% 1. Additionally, eosinophilic esophagitis has been identified as a risk factor for perforation, with a history of food impaction and presence of a focal stricture increasing the risk of perforation 1. It is essential to seek immediate medical attention if symptoms of esophageal perforation occur, such as severe chest pain, difficulty swallowing, or vomiting, as delay in treatment is the most important survival predictor 1. Treatment typically involves hospitalization, antibiotics, and supportive care, with surgery often necessary to repair the perforation.

From the FDA Drug Label

Esophageal adverse experiences, such as esophagitis, esophageal ulcers and esophageal erosions, occasionally with bleeding and rarely followed by esophageal stricture or perforation, have been reported in patients receiving treatment with oral bisphosphonates including alendronate sodium. The risk of severe esophageal adverse experiences appears to be greater in patients who lie down after taking oral bisphosphonates including alendronate sodium and/or who fail to swallow oral bisphosphonates including alendronate sodium with the recommended full glass (6-8 ounces) of water, and/or who continue to take oral bisphosphonates including alendronate sodium after developing symptoms suggestive of esophageal irritation. Gastrointestinal: esophagitis, esophageal erosions, esophageal ulcers, esophageal stricture or perforation, and oropharyngeal ulceration.

The causes of an esophageal perforation include:

• Oral bisphosphonate use, such as alendronate sodium, which can cause local irritation of the upper gastrointestinal mucosa
• Lying down after taking oral bisphosphonates
• Failing to swallow oral bisphosphonates with the recommended full glass of water
• Continuing to take oral bisphosphonates after developing symptoms suggestive of esophageal irritation 2
• Underlying esophageal diseases, such as esophagitis, esophageal ulcers, and esophageal erosions 2

From the Research

Causes of Esophageal Perforation

The causes of esophageal perforation can be categorized into several groups, including:

• Iatrogenic causes, such as those resulting from medical procedures like endoscopic dilation 3, 4
• Foreign body ingestion, which can lead to perforation of the esophagus 4
• Traumatic causes, including blunt chest trauma 5, 6 and penetrating injuries 5
• Other causes, such as stenosis post-endoscopic submucosal dissection for esophageal cancer 3

Risk Factors and Associations

Certain factors are associated with a higher risk of esophageal perforation, including:

• Delayed diagnosis, which can lead to increased morbidity and mortality 4, 6
• Elevated white blood cell count (WBC), which can indicate infection and inflammation 4
• Contrast leakage, which can be a sign of perforation 4
• Presence of abscesses or mediastinitis, which can complicate the clinical course 4

Clinical Presentation and Diagnosis

Esophageal perforation can present with vague symptoms, making diagnosis challenging 7, 5, 6. A high index of suspicion is necessary, particularly in cases of penetrating chest trauma or other traumatic injuries 5, 6. Diagnostic methods may include chest radiograph, computed tomography (CT) scans, and other imaging studies 7, 4.