Causes of Esophageal Rupture
Esophageal rupture is most commonly caused by iatrogenic injuries during endoscopic procedures (60%), followed by spontaneous rupture due to forceful vomiting (Boerhaave syndrome, 15%), and traumatic injuries. 1
Major Causes
Iatrogenic Causes
- Endoscopic procedures account for approximately 60% of all esophageal perforations 1
- Diagnostic and therapeutic endoscopy, including dilation procedures, are the most common iatrogenic causes 2
Spontaneous Rupture
- Forceful vomiting against a closed glottis (Boerhaave syndrome) accounts for about 15% of cases 1, 3
- Sudden increase in intraesophageal pressure during severe vomiting can lead to full-thickness tears 4
- Most commonly occurs in the distal esophagus on the left posterolateral wall 5
Traumatic Injuries
- External trauma to the esophagus is rare, accounting for less than 15% of all esophageal injuries 2
- Can be classified by anatomic location (cervical, thoracic, abdominal) and mechanism (penetrating, blunt) 2
- Blunt chest trauma causing esophageal rupture is extremely rare (0.001% incidence) 6
- Barotrauma from external air-blast injuries is an unusual cause 2
Other Causes
- Foreign body ingestion can cause direct injury to the esophageal wall 2
- Caustic ingestion (acids or alkalis) can cause severe damage leading to perforation 2
- Severe retching during procedures such as gastroscopy can cause spontaneous rupture 7
Risk Factors and Associated Conditions
- Pre-existing esophageal pathology increases risk of perforation 2
- Isolated esophageal trauma is rare; associated injuries to surrounding structures (spinal cord, airway, major vessels, lungs, heart) are common 2
- Anatomical position of the esophagus (predominantly left of midline in the cervical region) affects injury patterns 8
- Young males are most commonly affected by traumatic esophageal injuries 2
Clinical Implications
- Esophageal rupture has a high mortality rate (10-20%) if not promptly diagnosed and treated 1
- Delay in diagnosis (>24 hours) significantly worsens outcomes 2
- Complications include mediastinitis, empyema, sepsis, and rarely pulmonary artery pseudoaneurysm 9
- Thoracic esophageal trauma is associated with particularly high mortality rates 2
Warning Signs
- Sudden onset of thoracic pain (70%), fever (50%), dyspnea (25%), and subcutaneous emphysema (19%) after vomiting or procedures 2
- Tachycardia is a critical vital sign abnormality that should raise immediate suspicion 1
- Development of shock (pulse >100 beats/min and systolic BP <100 mmHg) is a warning sign requiring immediate attention 1
Understanding the various causes of esophageal rupture is crucial for early diagnosis and appropriate management, as treatment within the first 24 hours significantly improves survival outcomes 2.