Symptoms of Esophageal Perforation
Esophageal perforation presents with pain, breathlessness, fever, and tachycardia as the primary symptoms that should prompt immediate medical attention to reduce the high mortality rate of 10-20%. 1
Key Clinical Presentations
- Pain: Chest pain is the most common symptom, present in approximately 71% of cases, and may be persistent rather than transient 2
- Respiratory symptoms: Breathlessness/dyspnea occurs in about 24% of patients and may indicate mediastinal contamination 2, 1
- Fever: Present in approximately 51% of cases, indicating inflammatory response to contamination of surrounding spaces 2
- Tachycardia: A critical vital sign abnormality that should raise immediate suspicion of perforation 1
- Subcutaneous emphysema: Crepitus on physical examination is found in approximately 22% of patients 2, 1
Location-Specific Symptoms
- Thoracic perforations: More serious with higher mortality, presenting with severe chest pain radiating to the back, shoulders, or abdomen 1, 3
- Cervical perforations: May present with neck pain, dysphagia, and cervical crepitus 2
- Abdominal perforations: Often present with epigastric pain radiating to the back 2
Diagnostic Indicators
- Laboratory findings: While no specific patterns exist in early stages, later stages show signs of inflammation and sepsis 1
- Imaging findings: Indirect signs on chest radiograph may include:
- Pneumomediastinum
- Pneumothorax
- Air under the diaphragm
- Pleural effusion
- Subcutaneous emphysema 1
Time Course and Progression
- Early presentation: Pain and respiratory symptoms predominate 1
- Delayed presentation: Progression to sepsis with fever, tachycardia, and hemodynamic instability 1, 3
- Boerhaave syndrome (spontaneous perforation): Often presents after forceful vomiting or retching with sudden, severe chest pain 1, 4
Risk Factors and Causes
- Iatrogenic causes: Account for 60% of perforations, occurring during endoscopic procedures 1
- Spontaneous perforation: Accounts for 15% of cases, often due to forceful vomiting (Boerhaave syndrome) 1
- Other causes: Trauma, malignancy, foreign bodies, and caustic ingestion 1
Warning Signs Requiring Immediate Attention
- Persistent pain (versus transient pain which is common after procedures) 1
- Development of shock: Indicated by pulse >100 beats/min and systolic BP <100 mmHg 5
- Respiratory distress: Progressive difficulty breathing 1, 3
- Rapid clinical deterioration: Suggests mediastinal contamination and developing sepsis 1, 6
Key Considerations
- High clinical suspicion is essential as >50% of cases have delayed diagnosis 1
- Mortality increases significantly with delayed treatment beyond 24 hours 2, 7
- Contrast-enhanced CT is the imaging examination of choice with 92-100% sensitivity 1
Early recognition of these symptoms is crucial as mortality ranges between 10-20%, with delay in treatment being the most important predictor of survival 1, 6.