An esophageal perforation is a hole in the esophagus (the tube through which food passes from the mouth to the stomach).

The esophagus is a muscular tube that serves as a conduit for the passage of food and fluid from the mouth to the stomach. Perforation is the presence of a hole through which the contents of the esophagus can pass into the mediastinum (the surrounding area in the chest). This often results in infection of the mediastinum or mediastinitis.

The most common cause (more than 75%) of esophageal perforation is injury during a medical procedure such as esophagoscopy (a procedure to examine the esophagus) or placement of a naso-gastric tube.

The esophagus can also become perforated as the result of a disease process such as a tumor or gastric reflux with ulceration; a mechanical problem such as violent retching and vomiting; ingestion of a foreign body or caustic agents.

Still less common causes include injuries from penetrating or blunt trauma or injury to the esophagus during an operation on another organ near the esophagus. Cases have also very rarely been associated with childbirth, defecation, seizures, heavy lifting, and forceful swallowing.

The main symptom is pain at first, but the condition can progress to shock and even death if untreated.

For patients with perforation of the uppermost portion of the esophagus, neck pain or stiffness and air bubbles underneath the skin may be present.

For patients with perforation of the mid-portion or lower-most portion of the esophagus, difficulty swallowing, chest pain and difficulty breathing may be present.

Signs include fast breathing, rapid heart rate, low blood pressure and fever. A chest X-ray may demonstrate air in the soft tissues of the chest, fluid that has leaked from the esophagus into the space around the lungs, or collapse of the lung(s).

A chest CT scan may demonstrate formation of an abscess in the chest or evidence of esophageal cancer. A water-soluble contrast swallow (motion picture X-rays after drinking dye) may show the location of the perforation.

The treatment can be divided into initial and definitive phases. Early surgery is appropriate for almost all patients. Every effort should be made to have surgery within 24 hours of the occurrence of the perforation.

The initial phase includes: diagnostic studies to determine the location and cause of the hole, administration of IV fluids, and administration of IV antibiotics to prevent or treat infection. Fluid that has collected around the lung(s) may be treated with a chest tube to drain it away.

Repair of the perforation is the definitive treatment. For some patients with perforation in the uppermost (neck region) of the esophagus, the perforation may heal by itself if the patient does not eat or drink for a period of time. In this case, nutrition must be provided by another source such as a stomach feeding tube.

For perforation in the mid-portion and lower-most portions of the esophagus, operation is usually required for repair. Depending on the size and location of the perforation, the leak can be treated by simple repair or by removal of the esophagus.

Possible complications include:

• Permanent damage to the esophagus (e.g., narrowing)
• Abscess formation in and around the esophagus
• Infection in and around the lungs.

Demand immediate medical attention if you are in the hospital. If not, go to the emergency room or call the local emergency number (such as 911) if you have recently had surgery or the placement of a tube in the esophagus and have pain, difficulty swallowing or breathing, or have other reason to suspect you may have esophageal perforation. Time is of the essence in treating this condition.

Because of their nature, these injuries are difficult to prevent.