ASGE Annual GI Advanced Practice Provider Course (Virtual) - Clinical Case-based Learning (Day Two) | March 2025-Management of Esophageal Perforation

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The document discusses the endoscopic management of esophageal perforation, a critical medical condition characterized by the rupture of the esophagus. This can lead to severe complications such as sepsis, mediastinitis, pleural effusion, pneumonia, multi-organ failure, and potential fistula formation, which all contribute to a high mortality rate. <br /><br />Esophageal perforations are predominantly iatrogenic, occurring during endoscopic procedures or surgery, and are more frequent in males over 70 years, or patients undergoing strict dilation. Spontaneous causes include Boerhaave Syndrome (linked to vomiting), trauma, and malignancy-related perforation. <br /><br />Clinical presentation involves symptoms like severe chest pain, dysphagia, fever, and signs of systemic compromise, such as sepsis. Diagnosis relies on imaging, primarily CT scans and esophagrams, with initial management involving hemodynamic stabilization, fasting, intravenous fluids, broad-spectrum antibiotics, antifungal agents, and proton pump inhibitors. <br /><br />Endoscopic management is preferred for stable patients, with options for primary closure including endoscopic clips and suturing, or the use of esophageal stents. Clips are beneficial for smaller perforations, while suturing is suited for larger tears. Stents can be used for both benign and malignant perforations, providing a seal to facilitate healing. Endoluminal vacuum-assisted closure is effective for persistent esophageal leaks or postoperative issues, using a sponge connected to vacuum pressure to promote closure over weeks.<br /><br />Two case studies illustrate practical management: an elderly man post-esophageal surgery experiencing anastomotic perforation, where endoluminal vacuum therapy was successfully employed; and a young woman with Boerhaave Syndrome, managed conservatively without surgery following the absence of esophageal leakage on imaging. The document underscores the importance of early intervention, multidisciplinary care, and the increasing preference for endoscopic techniques in treating esophageal perforations.

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Katelyn Cookson, PA-C

Keywords

esophageal perforation

endoscopic management

iatrogenic causes

Boerhaave Syndrome

endoscopic clips

esophageal stents

endoluminal vacuum therapy

multidisciplinary care

hemodynamic stabilization

broad-spectrum antibiotics