The esophagus is the food pipe or swallowing tube that connects the mouth to the stomach. A tear in the esophagus is a medical emergency. Esophageal tears (holes in the esophageal wall) allow food, bacteria, and chemicals to escape from the esophagus into the chest cavity. A rupture or perforation of the esophagus can therefore lead to infection, inflammation, and other serious complications. 

Please continue reading to learn why esophageal ruptures occur, the symptoms of a perforated esophagus, and the treatment for this serious medical condition.

What is an esophageal perforation?

An esophageal perforation or rupture is a hole in the esophagus. It is a rare but potentially life-threatening condition. 

Esophageal perforations are serious because they can lead to severe infections of the chest, lungs, and bloodstream. It is critical to confirm the diagnosis and treat an esophageal tear within 24 hours to ensure survival and a good outcome.

Notably, an esophageal perforation is not the same thing as a Mallory Weiss tear. Mallory Weiss tears are injuries to the soft tissues (inner lining) of the esophagus that do not go all the way through the esophageal wall.

Who is at risk of esophageal tears?

Anyone can develop a perforation in their esophagus. However, some people are at a higher risk of esophageal tears, including those with chronic acid reflux, esophageal diverticulum, esophagitis, esophageal cancer and radiation therapy, esophageal surgery, and alcohol use.

What would cause your esophagus to tear?

An esophageal perforation can happen in the cervical esophagus (neck portion) or the middle or bottom portions. Esophageal perforations sometimes occur suddenly during a traumatic event. They can also happen more slowly over time, for instance, if chronic acid reflux gradually eats away at the esophageal wall, ultimately leading to a perforation. Sustained pressure on the wall of the esophagus from a foreign object or tumor can lead to death of the tissues and esophageal rupture. Some of the common causes of esophageal tears are listed below.

Injuries

The most common cause of an esophageal rupture is an injury. This can be an internal injury, for example, from swallowing a caustic chemical or foreign object (e.g., animal bones). It can be an external blunt or penetrating injury, for example, from a stabbing, gunshot wound, or motor vehicle accident. 

Iatrogenic perforation

Sometimes esophageal perforations occur during a medical procedure, such as an endoscopic procedure. Esophageal ruptures can also occur during surgical procedures like a Nissen fundoplication (done to treat gastroesophageal reflux disease). An esophageal tear that occurs during surgical or medical procedures is called an iatrogenic esophageal injury. 

Boerhaave syndrome

Rarely, the underlying cause of an esophageal rupture is tremendous stress on the esophagus due to vomiting, weightlifting, or childbirth. This type of spontaneous rupture is called Boerhaave syndrome.

What happens if your esophagus tears?

As mentioned above, an esophageal tear allows food, bacteria, and caustic chemicals to enter the chest cavity. This can lead to potentially life-threatening infections of the lungs, chest, and bloodstream. That’s why it’s important to recognize the signs and symptoms of an esophageal rupture and go to the nearest emergency room to receive treatment. 

Emergency esophageal surgery can help to prevent infection and other complications of an esophageal perforation. If left untreated, possible complications of an esophageal perforation include:

• Pleurisy (inflammation of the pleura or lining of the chest cavity)
• Pleural effusion (a buildup of fluid in the pleura which can cause it to burst)
• Mediastinal emphysema (trapped air in the mediastinum or the space between the lungs)
• Necrosis or tissue death of the mediastinum or pleura
• Septicemia (bloodstream infection)
• In extreme cases, sepsis (a life-threatening reaction that can end in organ failure and death)

What are the symptoms of an esophageal rupture?

The most common symptoms of an esophageal perforation are severe vomiting or violent vomiting, vomiting blood, difficulty swallowing, chest pain, shortness of breath, fast heartbeat, nausea, fever, and low blood pressure. 

Most esophageal ruptures occur in the mid or lower part of the esophagus, which is in the chest. If the esophageal perforation is higher, you may feel pain in your neck or right shoulder, and air bubbles may be visible under your skin. Lower esophageal perforations can cause abdominal pain.

Can a tear in the esophagus heal?

A Mallory Weiss tear (partial tear) in the esophagus can heal on its own, or it may need treatment. 

Some perforations in the upper (neck) part of the esophagus can heal on their own. However, for this to occur, you will need to refrain from eating or drinking for a period of time. This means you will need to get your nutrition through a feeding tube while your esophagus heals. 

Surgical repair is often required to repair esophageal tears in the middle or bottom parts of the esophagus.

How do doctors diagnose esophageal tears?

Doctors diagnose esophageal perforations with imaging studies such as a chest x-ray, an esophagram (a special x-ray done using contrast material), or a CT scan.

What is the treatment for esophageal ruptures?

The treatment for an esophageal rupture typically consists of the following:

• IV fluids to replace lost fluids.
• Broad-spectrum antibiotics and antifungals to prevent infection.
• Placement of a feeding tube for nutrition.
• Percutaneous drainage using a chest tube to remove fluid from body cavities.
• An endoscopic procedure for a simple repair of the perforation using clips, sutures, vacuum sponge, or stent placement.
• Esophageal surgery (opening up the chest to directly repair the injury).

How long does it take an esophageal tear to heal?

An esophageal tear usually heals in 3-4 weeks after successful esophageal surgery. Early diagnosis and treatment are critical. People who receive treatment for an esophageal perforation within 24 hours have a survival rate of 85%. On the other hand, if treatment is delayed to 48 hours or more, the survival rate is only 50%.

References:

1. https://my.clevelandclinic.org/health/diseases/24284-esophageal-rupture