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Injuries to the Esophagus

 

Causes

Injuries to the esophagus are caused by objects (swallowed foreign bodies, endoscopes) or stabbing injuries from thorax traumas or by burns with acid or lye. A rare cause of injury is the Boerhaave Syndrome. Here violent vomiting after extensive eating and alcohol consumption results in a perforation in the esophagus. 

 

Symptoms

Chest pain or pain in the back or upper abdomen depending on which part of the oesophagus is affected, blood vomiting, swallowing disturbances, shortness of breath, fever.

 

Signs 

Depending on the type of injury various signs that are seen are dyspnoea (difficulty in breathing), tenderness over the epigastrium (midline area below the breast bone), cyanosis, subcutaneous emphysema in the neck, pneumothorax (collapsed lung) or pleural effusion.

 

Diagnostic

Chest X-ray after few hours shows air or fluid in the pleural cavity & mediastinal emphysema. X-rays taken after swallowing of a water-soluble contrast medium.

 

Treatment Modalities

Small injuries not involving inflammation of adjacent tissue can be treated conservatively by keeping the patient nil by mouth (no oral intake allowed) along with hyperalimentation and intravenous antibiotic protection, and a drainage tube in the wound whenever needed.

 

In the case of injuries from acid or lye, a thorough flushing of the esophagus and stomach with lots of water is done. Medications (steroids and antibiotics) prevent excessive swelling of the mucous membrane or an infection.

 

In a large injury involving a complete perforation of the esophagus and wide spread inflammation in the surrounding area, surgery must often be performed. The general rule is: The faster the surgery is performed the greater the survival rate. Injuries with perforation of the esophagus below the diaphragm and leakage of saliva and stomach juices into the abdominal cavity present as an "acute abdomen" and demand fast surgical treatment. Injuries with perforation in the thoracic part of the oesophagus present as respiratory emergencies, which also need fast intervention. 

 

Surgical Therapy

The choice of surgical procedure depends upon the location of the injury. Injuries in the upper part of the esophagus call for access to the esophagus in the neck area by opening the chest cavity. Access to injuries of the lowest section of the esophagus can be achieved by opening the upper abdomen with a horizontal incision. Small and new injuries can be treated with a local suture. Large injuries with inflammation of the surrounding area often demand a more radical procedure that involves removal of the affected part of the esophagus and external deviation of the esophagus creating a fistula in the neck. Food can then be temporarily given through a feeding tube that has been placed through the skin into the duodenum. When the inflammation has completely subsided usually after 3-6 months, restoration of the oesophgeal continuity can be achieved by reconstructive surgery, either by drawing up the stomach or by using a colon segment interposition. (see oesophageal carcinoma).

 

Complications

Complications, especially in the case of injuries affecting a large area, can be considerable. Mediastinitis (inflammation of the mediastinum = the cavity between the lungs. the mediastinum contains the heart, the large vessels, the trachea, the esophagus, the thymus, and connective tissues.) has a 50% fatality rate. Burns from acid or lye can cause a glottis edema with shortness of breath and danger of suffocation. Complications of surgery are explained in detail in the paragraph "Esophageal Tumors". The speed of treatment in a specialized center is very important.

 

Aftercare

Injuries to the esophagus with perforation and surgical treatment usually require lengthy medical care in an intensive care unit. The primary difficulties are often related to artificial respiration, secondary disease of the lungs, and microbial infections. The extent of rehabilitation depends on the degree of the disease. Patients with neck fistula must have regular check-ups at short intervals by his family physicians. The reconstruction operation is described in detail in the paragraph "Esophageal Tumors".