What is the most common cause of esophageal perforation?

From the Guidelines

The most common cause of esophageal perforation is iatrogenic, accounting for 60% of cases, particularly during diagnostic and therapeutic endoscopic procedures. This is supported by the World Journal of Emergency Surgery study 1, which highlights that the large majority of esophageal perforations are iatrogenic.

Key Points

• Iatrogenic causes, such as esophageal dilation, varices ligation, and sclerotherapy, are the leading causes of esophageal perforation
• Boerhaave syndrome, or spontaneous esophageal perforation, accounts for only 15% of cases and is typically caused by an abrupt increase in esophageal pressure following a vomiting effort
• Other rare causes of esophageal perforation include operative and external trauma, malignancy, foreign bodies, and caustic ingestion
• The contamination of surrounding spaces with digestive contents can lead to severe sepsis and death if left untreated, with mortality rates ranging from 10% to 20% 1

Clinical Implications

• Prompt diagnosis and treatment are crucial in reducing mortality rates and improving outcomes for patients with esophageal perforation
• Treatment typically involves antibiotics, nothing by mouth, and often surgical intervention depending on the size and location of the perforation
• It is essential to recognize the signs and symptoms of esophageal perforation, including severe chest pain, difficulty swallowing, and fever, to initiate timely treatment and prevent complications.

From the Research

Causes of Esophageal Perforation

• The most common cause of esophageal perforation is iatrogenic disruption, as stated in the study 2.
• Other causes of esophageal perforation include:
  • Gunshot injury
  • Stab wound
  • Foreign body
  • Malignant perforation
  • Postemetic perforation
• The study 3 reports that patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality and composite morbidity.

Risk Factors for Morbidity and Mortality

• Risk factors for mortality include:
  • Age >65 years, as reported in the study 3
  • Malignant perforation, as reported in the study 3
• Risk factors for composite morbidity include:
  • Pleural contamination, as reported in the study 3
  • Sepsis, as reported in the study 3

Management of Esophageal Perforation

• Management principles include:
  • Adequate fluid resuscitation
  • Expeditious administration of appropriate broad-spectrum antibiotics
  • Repair, occlusion, exclusion, diversion, or exteriorization of the perforation site
  • Drainage of extraluminal fluid collections
  • Relief of distal obstruction
  • Nutritional support, as reported in the study 4
• Endoscopic therapies, including stenting, clipping, suturing, or endoscopic vacuum therapy, have been introduced as a more minimally invasive approach for management, as reported in the study 5.