Esophageal Injury


Background
  1. Rare injury
  2. A delayed threat to life
  3. Can be due to blunt or penetrating trauma
  4. Most lacerations are non-traumatic

Pathophysiology

  1. Esophagus is well protected
  2. If traumatic injury is sustained, most patients die in the field
  3. Injuries have high mortality / prolonged morbidity
  4. Anatomical considerations

Diagnosis

  1. Signs & symptoms
  2. Laboratory
  3. Imaging

Differential Diagnosis

  1. Thoracic Aortic Aneurysm
  2. Spontaneous pneumomediastinum
  3. Myocardial infarction
  4. Pneumonia
  5. Pulmonary embolus
  6. Mesenteric thrombosis
  7. Perforated peptic ulcer
  8. Pancreatitis
  9. Cholecystitis

Treatment

  1. ATLS
  2. Should be found during secondary survey
  3. Zone II neck injuries (between clavicles & cricoid cartilage) with vascular injury or instability may be surgically explored
  4. Esophagogram w/water soluble contrast
  5. Endoscopy to follow esophagogram
  6. Endoscopy for pts going to surgery for other reasons
  7. Management

Disposition

  1. Admit for surgical repair & antibiotics
  2. Treat early
  Physical Exam Investigations Management
Pulmonary Contusion - Blunt trauma to chest
- Interstitial edema impairs compliance and gas exchange
- CXR: areas of opacification of lung within 6 hours of trauma - maintain adequate ventilation
- monitor with ABG, pulse oximeter and ECG
- chest physiotherapy
- positive pressure ventilation if severe
 
Ruptured Diaphragm - Blunt trauma to chest or abdomen (e.g. high lap belt in MVC) - CXR:  abnormality of diaphragm/lower lung fields/NG tube placement   
- CT scan and endoscopy - sometimes helpful for diagnosis
- laparotomy for diaphragm repair and because of associated intra-abdominal injuries
Esophageal Injury - Usually penetrating trauma (pain out of proportion to degree of injury) - CXR: mediastinal air (not always)
- Esophagram (Gastrograffin)      
- Flexible esophagoscopy
- Early repair (within 24 hrs.) improves outcome but all require repair
Aortic Tear    
 
- 90% tear at subclavian (near ligamentum arteriosum), most die at scene
- salvageable if diagnosis made rapidly
- Sudden high speed deceleration (e.g. MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent)

- Decreased femoral pulses, differential arm BP (arch tear)
- CXR, CT scan, transesophageal echo (TEE), aortography (gold standard)
- see below for CXR features
- Thoracotomy (may treat other severe injuries first)
Blunt Myocardial Injury (Rare) - Blunt trauma to chest (usually in setting of multi-system trauma and therefore difficult to diagnose)      
- Physical examination: overlying injury, i.e. fractures, chest wall contusion
- ECG: arrhythmias, ST changes
- Patients with a normal ECG and normal hemodynamics never get dysrhythmias
- O2
- Antiarrhythmic agents
- Analgesia