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Spontaneous rupture of the esophagus
Spontaneous
Rupture
of the Esophagus*
WILLIAM H. HARRISON, JR., M.D. AND JOHN R. DERRICK, M.D., Galveston, Texas
From the Division of Thoracic and Cardiovascular Surgery, University of Texas Medical Branch, Galveston, Texas.
moderate hypertension, and an electrocardiogram in 1953 showed some myocardial ischemia. He was not a heavy drinker. On physical examination he was afebrile with pulse 110, respirations 35, and blood pressure lSO/SO mm. Hg. His skin was cold and clammy and he felt faint. The chest was clear and there was no friction rub. The heart sounds were,normal except for a grade II systolic murmur at the base, and the abdomen was soft and nontender with good peristalsis. It was thought that the patient had had an acute myocardial infarction. An electrocardiogram suggested anterior subepicardial infarction. On the way to the x-ray room he collapsed and blood pressure dropped to 100/60 mm. Hg. The chest roentgenogram (Fig. 1) showed no hydropneumothorax or mediastinal or subcutaneous emphysema, and was interpreted as normal. A complete blood count and urinalysis were within normal limits. He was treated for myocardial infarction with oxygen, bedrest, and sedation. The following day the patient’s temperature had risen to 101’ F. and severe apprehension and pleuritic pain developed. A chest roentgenogram was interpreted as showing congestive heart failure. The patient’s condition had become worse and the blood pressure was maintained with pressor agents. Finally, on the third day, the patient demonstrated hydropneumothorax and a surgeon was consulted to insert a thoracotomy tube. The then suspected diagnosis of spontaneous rupture of the esophagus was confirmed with a 5 cc. methylene blue swallow which promptly appeared in the thoracotomy bottle. The patient was then vigorously treated with antibiotics, chest tube irrigation and drainage, hydration, and transfusions in a Fowler’s position. By the next day, April 10, his condition had improved and he was no longer in shock. He underwent surgery, and a sump modification of a Stamm gastrostomy and a Witzel jejunostomy were performed followed immediately by left thoracotomy with debridement and adequate thoracotomy drainage. The esophageal
PONTANEOUS RUPTURE of the esophagus is a rare and often difficult condition to diagnose early, and a condition which is quite often fatal. Even though it was first described as early as 1724 by Boerhaave [1,2] the first antemortem diagnosis was not made until 1858 by Myers [3]. The first successful drainage procedure was accomplished in 1941 by Frank [4] followed in 1943 by Overholt [5] and in 1944 by Graham [6]. It was not until 1947 that the first successful direct closure of the perforation at surgery which did not dehisce was performed by Olsen and Clagett [7]. This paper serves to review briefly the signs and symptoms of this illness and to plea for early diagnosis and prompt surgical intervention. A method of treatment utilizing suction gastrostomy, feeding jejunostomy, closure of the perforation, and adequate drainage in these cases, especially when the diagnosis has been delayed, is described. S
CASE REPORT
The afternoon of April 7, 1962 a fifty-seven year old white man was admitted to the hospital in shock. He stated that while swallowing a particularly large bite of corned beef he had a sensation that it had lodged in the esophagus and he went to the bathroom where he forcefully vomited. Immediately thereafter he had sudden severe pain in the lower part of the chest and upper part of the abdomen and “felt like passing out.” He was rushed to the hospital by ambulance. Past history revealed that he had a peptic ulcer in 1953 and in November 1961. He had received treatment with diet and anticholinergic drugs. He also had
* Presented at the Twentieth Annual Meeting of the Southwestern Surgical Congress, Denver, Colorado, April 22-25, 1968. 708
The American Journal of Surgery
Spontaneous Rupture of.Esophagus
FIG. 1 .in initial chest roentgenogram hour< (11rupture that was “normal.”
within
two
pcrioration (Fig. 2) was identified just above the diaphragm on the left, but due to the marked mediastinitis and friability of the esophagus, it could not be closed primarily. The gastrostomy and esophageal drainage kept the stomach decompressed and the gastric juices mixed with other liquids were placed into the jejunostomy by dril). The patient’s hydration and nutrition were thus adequately maintained. (Fig. 3.) The listula gradually narrowed and on May 16 it
A FIG. 2. A and B, a 3 cm. perforation trast material. Vol. 116, Novembev 1968
FIG. 3. Diagram showing the type of surgery performed in the three patients mentioned. was demonstrated to be closed on barium swallow. (Fig. 4.) The patient was discharged six weeks postoperatively on a bland diet. He has been followed up regularly since then over the past six years and continues to work and is free of symptoms. (Fig. 5.)
just above the diaphragm
B is demonstrated
with con-
710
Harrison
and Derrick
free of symptoms.
Comment: Two other patients with spontaneous rupture of the esophagus have been successfully managed in this fashion. In one patient with bilateral hydropneumothorax after spontaneous rupture, however, because of a prolonged fourteen hour period of shock prior to seeking medical attention, uremia developed and death occurred on the tenth postoperative day. At autopsy the primary esophageal repair was demonstrated to be healed. The cause of death was acute renal tubular necrosis. COMMENTS
Several points in the case presented deserve attention. The patient’s peptic ulcer symptoms prior to rupture suggest he may have had some acute esophagitis which predisposes to spontaneous rupture of the esophagus [8]. The onset did not occur after a drinking bout. There was a lack of hydropneumothorax or mediastinal emphysema on roentgenogram until the third hospital day. It is thought that the patient’s good nutrition and successful healing through the long convalescent course were due to the feeding jejunostomy performed early in the conrsf One should always suspect spontaneous rupture of the esophagus in any patient with acute chest or upper abdominal pain after emesis. The patients’ degree of symptoms progressively become worse over the next few hours and they become quite restless. They are dyspneic and show a preference for a sitting
position. Their demeanor reflects pain far out of proportion to any physical findings. The patient will present with increasing tachycardia and tachypnea and occasionally will show signs of subcutaneous emphysema. Examination of the chest may reveal signs of pneumo- or hydrothorax. Later as dehydration from fluid loss into the chest and perspiration increase, shock develops. In the later stages a pleuritic rub may develop although initially this is seldom seen. The upper part of the abdomen frequently is quite rigid and other intra-abdominal catastrophies might be considered. Quite often the diagnosis is difficult. The patient may be thought to have an acute myocardial infarction, pulmonary embolus, perforated peptic ulcer, or dissecting thoracic aneurysm. The diagnosis is usually established by means of a chest roentgenogram which will frequently reveal hydropneumothorax and/or mediastinal emphysema. However, an early chest roentgenogram may show nothing abnormal. (Fig. 1.) When hydropneumothorax develops, as will eventually occur, the diagnosis can readily be established by means of thoracentesis which will reveal gastric contents, and can be further confirmed by having the patient swallow a small amount of methylene blue which will promptly appear in the chest cavity. The exact site of perforation, which is usually a longitudinal tear on the left side of the esophagus just above the diaphragm, can be verified The American
Journal of Surgery
Spontaneous
Rupture
by means of a watersoluble contrast material or a thin barium swallow. (Fig. 2.) Surgery is the treatment of choice and should be prompt and vigorous. Since the patient’s condition at surgery is probably the best it will be for some days, gastrostomy and jejunostomy followed immediately by thoracotomy and closure of the perforation using the newer plastic sutures in two layers, with thoractomy drainage, should be performed. (Fig. 3.) Others have stated that if untreated, 90 per cent of patients with esophageal rupture will die within thirty-six hours, and with prompt diagnosis and immediate surgery the mortality is still nearly 65 per cent [Y]. It is believed that with earlier diagnosis and prompt surgical intervention as described [Fig. 3) the mortality should be significantly lowerec1 SUMMARY
Spontaneous rupture of the esophagus is a rare and frequently difficult condition to diagnose. Treatment should be prompt and surgery should be performed as soon as the patient’s condition permits. A surgical approach utilizing gastrostomy for decompression, jejunostomy for feeding,
Vol. 116, November
IQ68
711
of Esophagus
and primary closure of the esophagus wi t.h dcquate thoracotomy drainage performed :I\>oon as possible is described. X case w treatetl .uccessfully is presented and two others mentioned. REFERENCES
1. BOERHAAVE, 1-I. Atrocis, net descripti pru,i, x:lurbi hostoria: secundum medicae artis leg?< con, rnorbi historia (2). Bull. hf. Library .-I., 43: 217. 19%. 3. FITZ, R. H. Rupture of the healthy cwph;w.~s .Im. J. M. sci., 73: 17, 1877. 4. FRANK, N. W. Spontaneous rupture of the ewphagus. J. Thorucic Surg., 16: 491, 1941. 5. DERBES, V. J. and MITCHELL, R. E., JR. Rupture of the esophagus. .Swgery, 39: 688, I%%. 6. GRAHAM, E. A. Year Book of Surgery, 1944. Chicago, 1944. The Y’ear Book Publishers, Inc. 7. OLSEN, A. M. and CLAGETT, 0. T. Spontaneous rupture of the esophagus: report of a cab? with immediate diagnosis and successful sur!+xl repair. Postgrad. hled., 2: 415, 1947. 8. DERRICK, J. R., HARRISOX, \V. H., and IIUIYAIUI,J. Factors predisposing to spontaneous perforation of the esophagus. Surgery, 43: 486, 1958. 9. BRUXO, M. S., GRIER, W. R. X., and OBBR. \E:. B. Spontaneous laceration and rupture of esophagus and stomach. Mallory-Weiss syndrome, Bocrhaave syndrome and their variants. AYTII.In!. .Mrd., 112: 574, 1963.
Rupture
of the Esophagus*
WILLIAM H. HARRISON, JR., M.D. AND JOHN R. DERRICK, M.D., Galveston, Texas
From the Division of Thoracic and Cardiovascular Surgery, University of Texas Medical Branch, Galveston, Texas.
moderate hypertension, and an electrocardiogram in 1953 showed some myocardial ischemia. He was not a heavy drinker. On physical examination he was afebrile with pulse 110, respirations 35, and blood pressure lSO/SO mm. Hg. His skin was cold and clammy and he felt faint. The chest was clear and there was no friction rub. The heart sounds were,normal except for a grade II systolic murmur at the base, and the abdomen was soft and nontender with good peristalsis. It was thought that the patient had had an acute myocardial infarction. An electrocardiogram suggested anterior subepicardial infarction. On the way to the x-ray room he collapsed and blood pressure dropped to 100/60 mm. Hg. The chest roentgenogram (Fig. 1) showed no hydropneumothorax or mediastinal or subcutaneous emphysema, and was interpreted as normal. A complete blood count and urinalysis were within normal limits. He was treated for myocardial infarction with oxygen, bedrest, and sedation. The following day the patient’s temperature had risen to 101’ F. and severe apprehension and pleuritic pain developed. A chest roentgenogram was interpreted as showing congestive heart failure. The patient’s condition had become worse and the blood pressure was maintained with pressor agents. Finally, on the third day, the patient demonstrated hydropneumothorax and a surgeon was consulted to insert a thoracotomy tube. The then suspected diagnosis of spontaneous rupture of the esophagus was confirmed with a 5 cc. methylene blue swallow which promptly appeared in the thoracotomy bottle. The patient was then vigorously treated with antibiotics, chest tube irrigation and drainage, hydration, and transfusions in a Fowler’s position. By the next day, April 10, his condition had improved and he was no longer in shock. He underwent surgery, and a sump modification of a Stamm gastrostomy and a Witzel jejunostomy were performed followed immediately by left thoracotomy with debridement and adequate thoracotomy drainage. The esophageal
PONTANEOUS RUPTURE of the esophagus is a rare and often difficult condition to diagnose early, and a condition which is quite often fatal. Even though it was first described as early as 1724 by Boerhaave [1,2] the first antemortem diagnosis was not made until 1858 by Myers [3]. The first successful drainage procedure was accomplished in 1941 by Frank [4] followed in 1943 by Overholt [5] and in 1944 by Graham [6]. It was not until 1947 that the first successful direct closure of the perforation at surgery which did not dehisce was performed by Olsen and Clagett [7]. This paper serves to review briefly the signs and symptoms of this illness and to plea for early diagnosis and prompt surgical intervention. A method of treatment utilizing suction gastrostomy, feeding jejunostomy, closure of the perforation, and adequate drainage in these cases, especially when the diagnosis has been delayed, is described. S
CASE REPORT
The afternoon of April 7, 1962 a fifty-seven year old white man was admitted to the hospital in shock. He stated that while swallowing a particularly large bite of corned beef he had a sensation that it had lodged in the esophagus and he went to the bathroom where he forcefully vomited. Immediately thereafter he had sudden severe pain in the lower part of the chest and upper part of the abdomen and “felt like passing out.” He was rushed to the hospital by ambulance. Past history revealed that he had a peptic ulcer in 1953 and in November 1961. He had received treatment with diet and anticholinergic drugs. He also had
* Presented at the Twentieth Annual Meeting of the Southwestern Surgical Congress, Denver, Colorado, April 22-25, 1968. 708
The American Journal of Surgery
Spontaneous Rupture of.Esophagus
FIG. 1 .in initial chest roentgenogram hour< (11rupture that was “normal.”
within
two
pcrioration (Fig. 2) was identified just above the diaphragm on the left, but due to the marked mediastinitis and friability of the esophagus, it could not be closed primarily. The gastrostomy and esophageal drainage kept the stomach decompressed and the gastric juices mixed with other liquids were placed into the jejunostomy by dril). The patient’s hydration and nutrition were thus adequately maintained. (Fig. 3.) The listula gradually narrowed and on May 16 it
A FIG. 2. A and B, a 3 cm. perforation trast material. Vol. 116, Novembev 1968
FIG. 3. Diagram showing the type of surgery performed in the three patients mentioned. was demonstrated to be closed on barium swallow. (Fig. 4.) The patient was discharged six weeks postoperatively on a bland diet. He has been followed up regularly since then over the past six years and continues to work and is free of symptoms. (Fig. 5.)
just above the diaphragm
B is demonstrated
with con-
710
Harrison
and Derrick
free of symptoms.
Comment: Two other patients with spontaneous rupture of the esophagus have been successfully managed in this fashion. In one patient with bilateral hydropneumothorax after spontaneous rupture, however, because of a prolonged fourteen hour period of shock prior to seeking medical attention, uremia developed and death occurred on the tenth postoperative day. At autopsy the primary esophageal repair was demonstrated to be healed. The cause of death was acute renal tubular necrosis. COMMENTS
Several points in the case presented deserve attention. The patient’s peptic ulcer symptoms prior to rupture suggest he may have had some acute esophagitis which predisposes to spontaneous rupture of the esophagus [8]. The onset did not occur after a drinking bout. There was a lack of hydropneumothorax or mediastinal emphysema on roentgenogram until the third hospital day. It is thought that the patient’s good nutrition and successful healing through the long convalescent course were due to the feeding jejunostomy performed early in the conrsf One should always suspect spontaneous rupture of the esophagus in any patient with acute chest or upper abdominal pain after emesis. The patients’ degree of symptoms progressively become worse over the next few hours and they become quite restless. They are dyspneic and show a preference for a sitting
position. Their demeanor reflects pain far out of proportion to any physical findings. The patient will present with increasing tachycardia and tachypnea and occasionally will show signs of subcutaneous emphysema. Examination of the chest may reveal signs of pneumo- or hydrothorax. Later as dehydration from fluid loss into the chest and perspiration increase, shock develops. In the later stages a pleuritic rub may develop although initially this is seldom seen. The upper part of the abdomen frequently is quite rigid and other intra-abdominal catastrophies might be considered. Quite often the diagnosis is difficult. The patient may be thought to have an acute myocardial infarction, pulmonary embolus, perforated peptic ulcer, or dissecting thoracic aneurysm. The diagnosis is usually established by means of a chest roentgenogram which will frequently reveal hydropneumothorax and/or mediastinal emphysema. However, an early chest roentgenogram may show nothing abnormal. (Fig. 1.) When hydropneumothorax develops, as will eventually occur, the diagnosis can readily be established by means of thoracentesis which will reveal gastric contents, and can be further confirmed by having the patient swallow a small amount of methylene blue which will promptly appear in the chest cavity. The exact site of perforation, which is usually a longitudinal tear on the left side of the esophagus just above the diaphragm, can be verified The American
Journal of Surgery
Spontaneous
Rupture
by means of a watersoluble contrast material or a thin barium swallow. (Fig. 2.) Surgery is the treatment of choice and should be prompt and vigorous. Since the patient’s condition at surgery is probably the best it will be for some days, gastrostomy and jejunostomy followed immediately by thoracotomy and closure of the perforation using the newer plastic sutures in two layers, with thoractomy drainage, should be performed. (Fig. 3.) Others have stated that if untreated, 90 per cent of patients with esophageal rupture will die within thirty-six hours, and with prompt diagnosis and immediate surgery the mortality is still nearly 65 per cent [Y]. It is believed that with earlier diagnosis and prompt surgical intervention as described [Fig. 3) the mortality should be significantly lowerec1 SUMMARY
Spontaneous rupture of the esophagus is a rare and frequently difficult condition to diagnose. Treatment should be prompt and surgery should be performed as soon as the patient’s condition permits. A surgical approach utilizing gastrostomy for decompression, jejunostomy for feeding,
Vol. 116, November
IQ68
711
of Esophagus
and primary closure of the esophagus wi t.h dcquate thoracotomy drainage performed :I\>oon as possible is described. X case w treatetl .uccessfully is presented and two others mentioned. REFERENCES
1. BOERHAAVE, 1-I. Atrocis, net descripti pru,i, x:lurbi hostoria: secundum medicae artis leg?< con