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

A perforation is 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 (mediastinitis).

The most common cause of an esophageal perforation is injury during a medical procedure such as esophagoscopy. However, because flexible instruments are now used this rarely occurs.

The esophagus may also become perforated as the result of:

• A tumor
• Gastric reflux with ulceration
• Swallowing a foreign object or caustic chemicals
• Violent vomiting

Less common causes include injuries to the esophagus area (blunt trauma) and injury to the esophagus during an operation on another organ near the esophagus.

The main symptom is pain at first.

Patients with a perforation in the middle portion or lowermost portion of the esophagus may have difficulty swallowing, chest pain, and difficulty breathing.

Signs include:

• Fast breathing
• Fever
• Low blood pressure
• Rapid heart rate

Patients with a perforation in the top part of the esophagus may have neck pain or stiffness and air bubbles underneath the skin.

A chest x-ray may reveal air in the soft tissues of the chest, fluid that has leaked from the esophagus into the space around the lungs, or a lung collapse.

A chest CT scan may show an abscess in the chest or esophageal cancer. X-rays taken after you drink a non-harmful dye can help pinpoint the location of the perforation.

Almost all patients need early surgery. Every effort should be made to have surgery within 24 hours of when the perforation occurred.

The initial treatment may include:

• Administering fluids through a vein (IV)
• Administering IV antibiotics to prevent or treat infection
• Draining fluid that has collected around the lungs with a chest tube
• Bronchoscopy to remove fluid that has collected in the area behind the breastbone and between the lungs (mediastinum)

If little or no fluid has leaked, a stent may be placed in the esophagus. This may help you avoid surgery.

Sometimes a perforation in the uppermost (neck region) part of the esophagus may heal by itself if you do not eat or drink for a period of time. In this case, you must get nutrition from another source, such as a stomach feeding tube.

Surgery is usually needed to repair a perforation in the middle or bottom portions of the esophagus. Depending on the size and location of the perforation, the leak may be treated by simple repair or by removing the esophagus.

The condition can progress to shock -- even death -- if untreated.

For patients with an early diagnosis (less than 24 hours), the outlook is good. The survival rate is 90% when surgery is performed within 24 hours. However, this rate drops to about 50% when treatment is delayed.

Possible complications include:

• Permanent damage to the esophagus (narrowing or stricture)
• Abscess formation in and around the esophagus
• Infection in and around the lungs.

Demand immediate medical attention if you are already in the hospital.

Go to the emergency room or call 911 if you have recently had surgery or a tube placed in the esophagus and you have pain, difficulty swallowing or breathing, or another reason to suspect that you may have esophageal perforation. Time is of the essence in treating this condition.

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

Perforation of the esophagus

Kiey J, Amendola M, Bouhaider D, Sandhu BS, Zhao X, Maher J. A management algorithm for esophageal perforation. American J Surg. 2007;194:103-106.

Updated by: George F. Lonstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.