Esophageal perforation

1. CASE PRESENTATION Dr.YazeedOwiwi Pediatric Surgery Department FCPS-II Trainee, PGR-III

2. CASE HISTORY Patient name Tayyab. Sex Male Age 2 and half years old. Date of admission 24th march 2011. CHIEF COMPLAINT: Persistent fluid leaking through right chest tube for the last 1 month.

3. History of Present Illness:

4. Treatment given outside PIMS…

5. At presentation…(Day 7 after swallowing button battery)

7. Gastrografin study. Day 8

8. Esophagoscopy.Day 9 Esophagoscopy was attempted twicely. Button battery was removed. It was apparently intact.

9. Day 14.

10. Esophageal stent placed 3rd week.

11. Barium swallow 4th week.

12. Patient brought to PIMS 5th week Sick looking, emaciated child. Pale. Right chest tube placed with food particles and saliva coming out.

13. Day 1 of admission Pt kept NPO. N/G suction. Antibiotic cover. PPN started. Blood tranfused. Serial x-rays taken.

14. Day 7 of Admission Esophagoscopydone Findings: Food particles enterapted in esophagus. Lower 1/3 of esophagus was hyperaemic& edematous. SEMS found occuping lower 1/3 of esophagus. Endoscopy was unable to passfurther uptostomach due to edema.

15. Day 10 of Admission Feeding Jejunostomy placed. Enternal feeding started.

16. 3rd week of admission No fluid leaking from chest tube. Chest tube clamped for 24 hours and removed in next day.

17. 2 days latter.. Pt discharged from ward with regular follow up in OPD.

19. Productive cough.

20. Abdominal distension.

22. Chest x-ray..

23. Gastrograffin study…

24. Barium swallow…

25. Chest x-ray after intubation…

26. Overview Esophageal perforation is rare Roughly 300 cases reported per year The diagnosis is commonly missed/delayed Mortality is high Most lethal GI perforation Mortality falls with early dx/intervention

27. Survival depends on rapid dx and surgery Within 24 hours of rupture: 70-75% survival Within 25-48 hours: 35-50% survival Beyond 48 hours: 10% survival

28. Etiology: Traumatic Causes (MORE COMMON): Endoscopy or dilation procedures Stent placement most common cause (up to 25% cases) Vomiting or severe straining Stab wounds / penetrating trauma Blunt chest trauma (rarely) Non-Traumatic Causes (LESS COMMON): Neoplasm / Ulceration of esophageal wall Ingestion of caustic materials

29. Oesophageal perforation after button battery ingestion Button batteries are frequently swallowed by children. Significant damage may occur within very short period _ Mucosal damage: 1 hr after ingestion. _ Transmural damage: within 4 hrs. Mechanisim of damage: (Alkali, Electric charge, Pressure). May lead to eosophagotracheal fistula. All button battaries impacted in esophagus should be removed immediately( 24-48 hrs). Short period of observation is warranted.

30. Anatomy Esophagus lacks serosa More likely to rupture Site of rupture: More commonly on left side Due to instrumentation: distal esophagus Spontaneous: posterolateral esophagus Tears are usually longitudinal

31. Pathophysiology Air, Saliva, and Gastric contents released mediastinitis pneumomediastinum empyema can progress to sepsis, shock, resp failure

32. Presentation Pain lower anterior chest / upper abdomen may radiate to left shoulder / back Vomiting >> Hematemesis hematemesis: think Mallory-Weiss/varices Dyspnea Cough (precipitated by swallowing) Fever

33. On Exam Subcutaneous Emphysema Fever Tachycardia Tachypnea Cyanosis

34. On Exam… Upper Abdominal Rigidity Pneumothorax/Hydrothorax Respiratory Failure Sepsis Shock

35. Initial Imaging: X-ray PA and Lateral chest films Look for: Hydrothorax (L side > R side) Pneumothorax Hydropneumothorax Pneumomediastinum SubQ emphysema Mediastinal widening Pleural Effusion (L side > R side)

36. Initial Imaging: X-ray Upright abdominal film Look for subdiaphragmatic air

37. Interventional Imaging Look for extravasation of contrast Evaluate location and size of rupture Options Gastrografin Study Water-soluble contrast Barium Esophagram Positive in 22% of pts with non-diagnostic Gastrografin study results

38. CT scan Should be used if interventional study: Cannot be performed (sedation, etc) Cannot localize rupture or is nondiagnostic Look for: Tear in esophageal wall Pneumomediastinum Abscess in pleural space or mediastinum Commuication of esophagus with fluid collections

39. What to do next ICU admission NPO NG suction Broad-spectrum Abx Pain control: Narcotics

40. Indications for conservative mgmt No clinical signs of infection Perforation is contained / walled-off

41. What to do next… Early surgical intervention reduces mortality rate: 1st 24 hours! “He looks sick!” “I’m going to call the surgeons!”

42. THANK YOU