What is the most common cause of esophageal perforation?

Most Common Cause of Esophageal Perforation

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

Epidemiology and Classification of Esophageal Perforations

Esophageal perforations can be classified into several categories with the following distribution:

• Iatrogenic (60%): Most commonly associated with diagnostic and therapeutic endoscopic procedures 1
• Spontaneous/barogenic (15%): Also known as Boerhaave syndrome 1
• Other less common causes:
  • Operative and external trauma
  • Malignancy
  • Foreign bodies
  • Caustic ingestion
  • Penetrating neck injuries 1

Iatrogenic Perforation Details

Iatrogenic perforations are predominantly associated with:

• Diagnostic and therapeutic endoscopic procedures 1
• Esophageal dilation (risk varies by type):
  • Simple rings or peptic strictures (0.09%-2.2%)
  • Caustic or radiation-induced strictures (higher risk)
  • Pneumatic dilation for achalasia (0.4%-14%) 1
• Endoscopic mucosal resection in Barrett's esophagus (0-3%) 1
• Other procedures: varices ligation and sclerotherapy 1

The high prevalence of iatrogenic causes is consistently supported by multiple studies, with one study noting that therapeutic endoscopy was responsible for 97.3% of iatrogenic perforations 2.

Clinical Presentation

Patients with esophageal perforation typically present with:

• Acute sudden onset of pain after endoscopic intervention (most common symptom) 3
• Signs of inflammation and sepsis in later stages 1

Diagnostic Approaches

Accurate and prompt diagnosis is critical:

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

Treatment Options

Treatment should be initiated promptly as delay beyond 24 hours significantly increases mortality 1:

• Non-operative management: Safe and effective for early perforation (<24 hours) without clinical signs of sepsis 3
• Endoscopic management:
  • Over-the-scope clips (OTSCs) for perforations 1-2 cm in size (85.3% success rate) 1
  • Fully covered self-expanding metal stents (SEMS) for poor visibility or large tears 1
  • Overall healing rate of 80-90% 3
• Surgical management: Indicated when criteria for non-operative management are not met, including:
  • Primary repair
  • Esophageal exclusion and diversion
  • Esophagectomy 3

Prognosis and Outcomes

• Mortality rate for iatrogenic perforations is approximately 19% 3
• Early recognition within 24 hours significantly improves outcomes 3
• One study reported only 6.8% hospital mortality with an individualized approach 4
• No deaths occurred in patients diagnosed within 24 hours in one series, compared to 19% mortality when diagnosis was delayed beyond 24 hours 4

Important Clinical Caveat

The high prevalence of iatrogenic causes highlights the importance of careful technique during endoscopic procedures and maintaining a high index of suspicion for perforation in patients who develop chest pain following upper endoscopy. Any patient complaining of chest pain after an upper endoscopy should be considered to have an esophageal perforation until proven otherwise 5.