What is the most common cause of esophageal perforation?

The Most Common Cause of Esophageal Perforation

Iatrogenic injury is the most common cause of esophageal perforation, accounting for approximately 60% of all cases. 1

Etiology of Esophageal Perforations

Esophageal perforations can be classified by their causes:

1. Iatrogenic (60%):

   • Most commonly occurs during diagnostic and therapeutic endoscopic procedures
   • Includes esophageal dilation, varices ligation, sclerotherapy, etc. 1
   • Associated with a mortality rate of approximately 19% 2

2. Spontaneous/Barogenic (15%):

   • Also known as Boerhaave syndrome
   • Results from abrupt increase in esophageal pressure following vomiting effort
   • Usually located on left border of lower third of thoracic esophagus
   • Wall defect is typically large (3-8 cm) 1

3. Other less common causes:

   • Operative and external trauma
   • Malignancy
   • Foreign bodies
   • Caustic ingestion 1
   • Penetrating neck injuries

Risk Factors for Iatrogenic Perforation

Certain procedures carry higher risks of perforation:

• Esophageal dilation for simple rings or peptic strictures: 0.09%-2.2%
• Caustic or radiation-induced strictures: higher risk
• Pneumatic dilation for achalasia: 0.4%-14% 1
• EMR in Barrett's esophagus: 0-3% 1

Clinical Presentation and Diagnosis

The clinical presentation depends on the location and extent of perforation:

• Acute sudden onset of pain after endoscopic intervention is the most common symptom 2
• Signs of inflammation and sepsis develop in later stages 1

Diagnostic approach:

1. Contrast-enhanced CT and CT esophagography (sensitivity 92-100%) 1
2. Water-soluble contrast studies 2
3. Endoscopy in select cases with doubtful CT findings 1

Management Options

Treatment approach should be determined based on:

• Location and extent of injury
• Time interval between perforation and treatment
• Patient's general condition and comorbidities 3

Non-operative Management

• Safe and effective for early perforations (<24 hours) without clinical signs of sepsis 2
• Includes cessation of oral intake, antibiotics, and parenteral nutrition 4
• Success rate is higher when implemented early

Endoscopic Management

• Options include clips and esophageal stents
• Healing rate of 80-90% 2
• Over-the-scope clips (OTSCs) are effective for perforations 1-2 cm in size with 85.3% success rate 1
• Fully covered self-expanding metal stents (SEMS) can be used when visibility is poor or tears are large 1

Surgical Management

• Indicated when non-operative criteria are not met
• Options include primary repair, esophageal exclusion and diversion, or esophagectomy 2
• Surgical approach is more common in spontaneous perforations (89% of Boerhaave syndrome cases) 4

Prognostic Factors

The most important predictor of survival is early diagnosis and treatment:

• Delay in treatment >24 hours significantly increases mortality 1, 4
• In one study, no deaths occurred in patients diagnosed within 24 hours, compared to 19% mortality when diagnosis was delayed beyond 24 hours 4

Key Considerations in Management

1. Early recognition of suspicious symptoms within 24 hours
2. Appropriate investigations (CT, contrast studies)
3. Selection of optimal treatment based on individual factors
4. Multidisciplinary critical care approach 2

By following these principles, mortality can be reduced from the historical rate of approximately 19% to as low as 4.8% in recent series 5.