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The esophagus2nd LectureM.A.Kubtan1 . .M.A.Kubtan2 Perforation of the esophagus is usually iatrogenic (instrumental perforations at therapeutic endoscopy) it can be managed conservatively ( not all the time ).Barotrauma (spontaneous perforation). is often a life-threatening condition that regularly requires surgical intervention .M.A.Kubtan3PERFORATION

Potentially lethal complication due to mediastinitis and septic shock .Numerous causes, but may be iatrogenic .Surgical emphysema is virtuall pathognomonic .Treatment is urgent; it may be conservative or surgical, but requires specialised care .M.A.Kubtan4Perforation of the esophagus

Boerhaave syndrome :This occurs classically when a person vomits against a closed glottis.The pressure in the esophagus increases rapidly, and the esophagus bursts at its weakest point in the lower third sending a stream of material into the mediastinum and often the pleural cavity .Boerhaave syndrome is the most serious type of perforation . This causes rapid chemical irritation in the mediastinum and pleura followed by infection if untreated.

M.A.Kubtan5Barotrauma (spontaneous perforation)

M.A.Kubtan6 Barotrauma has also been described in relation to other pressure events when the patient strains against a closed glottis (e.g.defaecation, labour, weight-lifting).

The clinical history is usually of severe pain in the chest or upper abdomen following a meal or a bout of drinking.Associated shortness of breath is common.There may be a surprising amount of rigidity on examination of the upper abdomen, even in the absence of any peritoneal contamination.The diagnosis can usually be suspected from the history and associated clinical features.

M.A.Kubtan7Diagnosis of spontaneous perforation

A chest X-ray is often confirmatory with air in the mediastinum, pleura or peritoneum.Pleural effusion occurs rapidly .A contrast swallow or CT is nearly always required to guide managementM.A.Kubtan8Continue

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severe subcutaneous emphysema 33 years old womansecondary to prolonged labor during normal vaginal delivery

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M.A.Kubtan11A contrast swallow

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Aero digestive fistula is most common and usually encountered in primary malignant disease of the esophagus or bronchus.Erosion into an adjacent structure with fistula formation is more common.Free perforation of ulcers or tumors of the esophagus into the pleural space is rare .Coughing on eating and signs of aspiration pneumonitis may allow the problem to be recognized .M.A.Kubtan13Pathological perforation

Covering the communication with a self-expanding metal stent is the usual solution.Erosion into a major vascular structure is invariably fatal.M.A.Kubtan14Continue

Foreign bodies : The esophagus may be perforated during removal of a foreign body .Occasionally, an object that has been left in the esophagus for several days will erode through the wall.Instrumental perforation : Instrumentation is by far the most common cause of perforation.Perforation can occur in the pharynx or esophagus, usually at sites of pathology or when the endoscope is passed blindly.Perforation may follow biopsy of a malignant tumor.M.A.Kubtan15Penetrating injury

The esophagus may be perforated by guide wires, graduated dilators or balloons, or during the placement of self-expanding stents. The risk is considerably higher in patients with malignancy.M.A.Kubtan16Continue

Forceful vomiting may produce a mucosal tear at the cardia rather than a full perforation.In MalloryWeiss syndrome, vigorous vomiting produces a vertical split in the gastric mucosa.Tear immediately below the squamocolumnar junction at the cardia in 90% of cases.In only 10% is the tear in the esophagus .M.A.Kubtan17MALLORYWEISS SYNDROME

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Perforation of the esophagus usually leads to mediastinitis.The aim of treatment is to limit mediastinal contamination and prevent or deal with infection. The event causing the perforation (spontaneous vs. instrumental) .Underlying pathology (benign or malignant) .The status of the esophagus before the perforation (fasted and empty vs. obstructed with a stagnant residue).M.A.Kubtan19Factors influencing Treatment of esophageal perforations

attempted suicide.Accidental ingestion occurs in children and when corrosives are stored in bottles labeled as beverages.All can cause severe damage to the mouth, pharynx, larynx, esophagus and stomach.In general, alkalis are relatively odorless and tasteless, making them more likely to be ingested in large volume.M.A.Kubtan20CORROSIVE INJURY

Significant stricture formation occurs in about 50% of patients with extensive mucosal damage .M.A.Kubtan21Continue

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Multiple stricture of the body of esophagus

Most congenital malformations develop during embryonic life between the third and eighth weeks of gestation.

M.A.Kubtan23CONGENITAL MALFORMATIONS

A blind proximal pouch with a distal tracheo-esophageal fistula is the most common type. Affected infants typically present Soon after birth with frothy saliva .cyanotic episodes, exacerbated by any attempt to feed.The preceding pregnancy may have been complicated by maternal polyhydramnios.

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Esophageal atresia

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Is confirmed by failure to pass a 10 Fr oro-gastric tube into the stomach .The tube is visible within an upper esophageal pouch on the chest radiograph.The presence of abdominal gas signifies the tracheo-esophageal fistula.Associated anomalies are common and include cardiac, renal and skeletal defects.M.A.Kubtan26Diagnosis

Surgical repair : The esophageal ends are anastomosed.Division and repair of tracheo esophageal tract . M.A.Kubtan27Treatment of Esophageal Atresia

Infants with pure esophageal atresia and no tracheo-esophageal fistula . Usually best managed by a temporary gastrostomy .Delayed primary repair.Except for very-low-birth weight babies and those with major congenital heart disease, most infants with repaired esophageal atresia have a good prognosis.

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Anastomotic leak .Stricture .Recurrent fistula formation .Gastro- esophageal reflux.M.A.Kubtan29Potential postoperative complications