Esophageal Trauma

Penetrating non-iatrogenic injuries to the esophagus are a rare but life-threatening condition. Injury to adjacent structures, such as the trachea, and a delay in diagnosis of 24 hours are associated with a poor outcome. Primary surgical repair is the most successful treatment approach.

Most esophageal perforations are iatrogenic. The most common cause of non-iatrogenic esophageal perforation is spontaneous rupture (Boerhaave's syndrome), followed by foreign body ingestion, trauma, and malignancy.

Traumatic esophageal injuries are rare, with most large trauma centers treating only one to two cases per year, most of which are penetrating injuries. In a retrospective review of 34 trauma centers, only 433 penetrating esophageal injuries were reported over a 10-year span [1].

The most common etiology for traumatic rupture was gunshot (75 percent), followed by stab wounds, and other mechanisms.

Cervical esophageal injuries were the most common location for a non-iatrogenic traumatic perforation, with less than 5 percent involving more than one anatomical location (eg, neck and thorax). The most common adjacent site involved was the trachea (75 percent), although all nearby structures are at risk for injury with penetrating trauma to any portion of the esophagus.

The diagnostic evaluation of patients suspected of traumatic esophageal injury poses some unique challenges. In a review of 405 patients, most patients had no symptoms or signs of traumatic esophageal injury; dysphagia was present in only 7 percent and subcutaneous emphysema was identified in 19 percent [1]. The clinician must maintain a high degree of suspicion based on mechanism of injury (eg, gunshot, stab), site of injury (eg, neck, chest, abdomen), and the proximity of the esophagus to other documented injuries.

For patients who are clinically stable, flexible esophagoscopy is the preferred method of diagnosis to establish the diagnosis since esophagography has a false negative rate (10 to 43 percent). If a skilled endoscopist is not available, then esophagography is performed beginning with Gastrografin, and if no leak is identified, barium.

For patients who are clinically unstable or intubated, flexible endoscopy should be performed in the operating room by a skilled, experienced endoscopist. In a retrospective review, 55 patients with a suspected penetrating esophageal injury who underwent emergent flexible endoscopy at a median time of three hours after presentation, 6 had positive findings of whom 2 (3.6 percent) had a perforation confirmed at the surgical exploration and 4 had a negative surgical exploration (false positive endoscopic findings due to partial thickness injury and hemorrhage). No perforations were missed, and endoscopic findings altered management in 38 (69 percent). [2]

1: Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma 2001; 50:289.

2: Srinivasan R, Haywood T, Horwitz B, et al. Role of flexible endoscopy in the evaluation of possible esophageal trauma after penetrating injuries. Am J Gastroenterol 2000; 95:1725.

Thanks to Dr. Matt Kaminsky for this submission.