What is the most common cause of esophageal perforation: acid ingestion, alkaline ingestion, Gastroesophageal Reflux Disease (GERD), iatrogenic cause, or vomiting?

From the Guidelines

Iatrogenic cause is the most common cause of esophageal perforation, accounting for approximately 60% of all cases. This refers to perforation that occurs as a complication of medical procedures, particularly endoscopic interventions such as upper endoscopy, esophageal dilation, or placement of nasogastric tubes 1. The esophagus is particularly vulnerable to perforation due to its thin wall, lack of serosal covering, and relatively poor blood supply. During endoscopic procedures, direct mechanical trauma from instruments or excessive pressure during dilation can breach the esophageal wall. Other causes of esophageal perforation include Boerhaave syndrome (spontaneous rupture due to forceful vomiting), foreign body ingestion, and chemical injuries from acid or alkaline substances, but these occur less frequently than iatrogenic perforations.

Some key points to consider about esophageal perforation include:

• The mortality rate for esophageal perforation ranges between 10% and 20% 1
• Delay in treatment is the most important survival predictor 1
• Iatrogenic perforations can occur during various endoscopic procedures, with perforation rates varying depending on the specific procedure and underlying condition of the esophagus 1
• Prompt recognition and treatment of esophageal perforation are crucial to reduce morbidity and mortality, with treatment options including antibiotics, surgical repair, or conservative management depending on the severity and location of the perforation.

It's worth noting that while other causes of esophageal perforation, such as Boerhaave syndrome, foreign body ingestion, and chemical injuries, do occur, iatrogenic cause remains the most common cause, highlighting the importance of careful technique and patient selection during endoscopic procedures 1.

From the Research

Causes of Esophageal Perforation

• The most common cause of esophageal perforation is iatrogenic, which means it is caused by medical procedures or interventions 2, 3.
• Iatrogenic esophageal perforation is associated with a high mortality rate of 19% 2.
• Other causes of esophageal perforation include spontaneous perforation, which can be caused by tumors, Boerhaave syndrome, or unknown origin 4.
• Acid ingestion, alkaline ingestion, GERD, and vomiting are not listed as the most common causes of esophageal perforation in the provided studies.

Comparison of Causes

• A study published in 2010 found that iatrogenic or suicidal causes accounted for 33 out of 62 cases of esophageal perforation, while spontaneous causes accounted for 29 cases 4.
• Another study published in 2019 found that iatrogenic perforations were the most common cause of esophageal perforation, with dilation of benign stricture being the most common etiology 3.
• The studies suggest that iatrogenic causes are the most common cause of esophageal perforation, followed by spontaneous causes.

Treatment and Outcome

• The treatment of esophageal perforation depends on the cause, location, and severity of the perforation, as well as the patient's overall health 5, 6.
• Non-operative management, including esophageal stenting, can be effective in treating esophageal perforation, especially if diagnosed early 2, 3.
• Surgical management, including primary repair or esophagectomy, may be necessary in some cases, especially if the patient has severe general conditions or if non-operative management is not effective 4, 6.