Esophageal trauma

It’s about esophageal trauma in surgery

1. Esophageal Trauma SUBMITTED BY Jesnajoy Group:7 Facility of medicine:-5 th year 2 nd semester

2. Introduction Esophageal injury (EI) is a rare but challenging clinical finding in the setting of trauma . In this injuries/perforations are transmural disruptions of the esophagus that subsequently lead to leakage of intraluminal contents into the surrounding mediastinum . This causes local inflammation, systemic inflammatory response, and eventually the development of sepsis that results in significant morbidity and mortality. The site of perforation varies depending upon the cause. Instrumental perforation is common in the pharynx or distal esophagus.

3. Anatomy The esophagus is a fibromuscular tube, about 25 centimeters long in adult . which travels behind the trachea and heart, passes through the diaphragm and empties into the uppermost region of the stomach. The esophagus is divided into three main anatomical regions: cervical, thoracic, and intra-abdominal esophagus. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. It consists of the following four layers:External fibrous layer , Intermediate muscular layer , Intermediate submucosal layer , Internal mucosal layer

4. Epidemiology The frequency of esophageal injury is 3 in 100,000 in the United States. The distribution by location is as . Cervical - 27% , Intrathoracic - 54% , Intra-abdominal - 19% . Penetrating EI is more common than blunt EI, with a corresponding ratio of approximately 10-to-1 The most common etiologies in the United States are gunshot wounds (about 75%) and stab wounds (about 15%). The morbidity and mortality of esophageal injuries are usually determined by a combination of temporal, patient, and injury severity factors. Traumatic esophageal injuries often present a diagnostic challenge, especially because of the potential for damage to surrounding tissues and concurrent contamination. Consequently, the trauma surgeon must be aware of the various mechanisms of EI, employ a high index of clinical suspicion, and act in a timely manner when an injury is suspected.

5. Etiology Esophagus rupture is usually iatrogenic , the result of endoscopic procedures .Biggest risk during endoscopic procedures .(diagnostic endoscopy, endoscopic biopsy, variceal sclerotherapy, endoscopic stent placement, nasogastric tube placement , mini tracheotomy ) Foreign bodies (bones, denatures , button barriers ) Trauma (blunt ,penetrating, iatrogenic) Spontaneous Boerhaave syndrome

6. Non esophageal surgery ( Mediastinal and cervical-thyroid, lung, spine and mediastinal Tumours Malignancy of esophagus , , lung and other mediastinal structures Infective causes (candida, herpes, syphilis ,tuberculosis) Severe reflex and Mallory-Weiss tear Caustic agents (alkali, acid )

7. Pathophysiology Because the esophagus lacks a serosal layer, it is more vulnerable to rupture or perforation . Once a perforation occurs, retained gastric contents, saliva, bile, and other substances may enter the mediastinum, resulting in Mediastinitis. The degree of mediastinal contamination and the location of the tear determine the clinical presentation. Within a few hours, a polymicrobial bacterial invasion occurs, which can lead to sepsis and eventually , death. The mediastinal pleura often ruptures, and gastric fluid is drawn into the pleural space by the negative intrathoracic pressure. Even if the mediastinal pleura is not violated, a sympathetic pleural effusion often occurs . Direct tissue damage due to acidic enteric contents combined with bacterial contamination of the mediastinal pleura means that therapeutic level of systemic antibiotics may not be achieved their target site.

8. Clinical features TYPICAL SYMPTOMS Pain of variable location, commonly in the lower anterior chest or upper abdomen Vomiting Subcutaneous emphysema Neck pain Dysphagia Dyspnea Hematemesis Melena Back pain

9. ATYPICAL SYMPTOMS Shoulder pain Facial swelling Hoarseness Dysphonia

10. Physical Examination Fever , Crepitus , Tachycardia , Tachypnea , Cyanosis , Dyspnea , Upper abdominal rigidity , Shock , Local tenderness On inspection subcutaneous emphysema may be obvious,with neck and chest wall swelling , giving a characteristic cracking sensation palpation as trapped air moved within the tissue planes. Percussion of the chest wall will be resonant if a pneumothorax is present, or indeed dull if there is lung atelectasis. If presence of pneumomediastinum cracking sound upon auscultation and Makclers triad ,consist of thoracic pain ,vomiting and subcutaneous emphysema.

11. Complications Mediastinitis Intrathoracic abscess Sepsis Respiratory failure Shock

12. Diagnosis History and clinical examination Laboratory-FHG Radiography plain Neck X-ray lateral view Chest X-ray posterioanterior view Abdominal X-ray Radiology contrast Gastrografic study (water soluble contrast) The barium swallow study CT scan of chest and abdomen with contrast MRI chest and abdomen Ventilation perfusion scan ECG

13. Differential diagnosis Chronic gastric, and duodenal ulcer diseases Mayocardial infractions Acute pancreatitis Dissecting aortic aneurysms Pneumonia Pneumothorax

14. Management Medical Therapy A dmission to a medical or surgical intensive care unit (ICU) Nothing by mouth Parenteral nutritional support Nasogastric suction - This should be maintained until there is evidence to indicate that the esophageal perforation has healed, is smaller, or is unchanged . Along with parenteral nutrition PPI also given Broad-spectrum antibiotics - No randomized clinical trials exist for antibiotics and esophageal perforation; however, empiric coverage for anaerobic and both gram-negative and gram-positive aerobes should be initiated when the initial diagnosis is suspected . Narcotic analgesics

15. Non operative treatment Recent iatrogenic perforation or late iatrogenic or postemetic esophageal perforation Intrathoracic perforation Absence of sepsis Medical contraindications for surgery (eg, severe emphysema or severe coronary artery disease) Isolation of the leak within the mediastinum or between the mediastinum and visceral pleura (no extravasation of contrast into adjacent body cavities) No malignancy, obstruction, or stricture in the region of the perforation Minimal symptoms Drainage of perforation into the esophagus

16. Surgical therapy Tube thoracostomy ( drainage with a chest tube or operative drainage alone) Primary repair Primary repair with reinforcement with pleura, intercostal muscle, diaphragm, pericardial fat, pleural flap Diversio n Diversion and exclusion Esophageal resection Thoracoscopic repair Esophageal stenting Endoscopic placement of fibrin sealant Endoscopic suture ligation Endoluminal negative-pressure therapy

17. https:// www.ncbi.nlm.nih.gov /books/NBK470161/#article-21348.s1 https:// emedicine.medscape.com /article/425410-treatment# showall https:// www.ncbi.nlm.nih.gov / pmc /articles/PMC3219576/#! po =31.2500 Reference

18. Thank you