Injury to the Esophagus

Injury to the esophagus, although not often seen, is an intolerable condition in the absence of early detection and appropriate surgical intervention. The cause can be penetrating or blunt injury, iatrogenic injury, laceration from ingestion of a sharp object, or tissue destruction secondary to swallowing a caustic substance. Ingestion of alkaline or acid liquids can be accidental or purposeful. The esophagus is relatively impervious to injury but can be harmed gradually by backflow of acid from the stomach (gastroesophageal reflux or GERD. The esophagus may also be harmed suddenly by caustic or acidic chemicals, irritating drugs, a sharp object, or extreme pressure. Extreme pressure can occur during violent vomiting, and violent vomiting can cause tears in the esophagus. Iatrogenic injury—especially during endoscopy, tube insertion, forceful dilation, and balloon insertion or inflation—is the most common cause. Spontaneous rupture of the esophagus is relatively rare but can be as devastating as any of the causes described above.

Sudden injuries can cause pain, often felt as sharp pain under the breastbone. They may also cause bleeding, which would be evident in vomited material or stool. Fainting may occur due to this pain, especially if the esophagus ruptures. This rupture allows food contents to spill into the mediastinum (the area of the chest bordered by the sternum in front, the spinal column in back, the entrance to the chest cavity above, and the diaphragm below) and causes mediastinitis.

No single examination, test, or imaging technique is always diagnostic; therefore, multiple and combined tests are often required to confirm the esophageal injury. Imaging of the esophagus can be confusing and is overrated. Doctors use various methods to diagnose injuries of the esophagus. Methods include esophagoscopy and different types of x-rays.

Treatment

Treatment depends on the cause of the injury. Surgical procedures to repair an injured esophagus range from simple closure to total esophageal resection with later reconstruction. Thoracic esophageal injuries must always be approached via a posterolateral thoracic incision. The “safe” surgical option is the best for these injuries, and drainage of the esophageal injury or the infected mediastinum is always safe. In some instances, long-term conduit reconstruction might be required.