Esophageal Perforation and Rupture

Esophageal Perforation and Rupture 

Key Points

• Esophageal perforation or rupture is a life-threatening condition in which the cervical, thoracic, or intra-abdominal esophageal sections are perforated or ruptured iatrogenically, traumatically, spontaneously, or through the ingestion of foreign bodies
• Often results in the dissection of air along the subcutaneous planes or into the mediastinum, presenting with chest pain, dyspnea, fever, and neck pain
• Diagnosed clinically based on patient history, signs, and symptoms, and confirmed through visualization; chest radiograph (with water-soluble contrast if needed) is obtained in all patients, with CT scan obtained if needed, and esophagram (chest fluoroscopy with a water-soluble contrast medium) performed if other imaging is inconclusive
• Patients with esophageal perforation or rupture are considered critically ill and require immediate treatment and management in an ICU
• Treatment is dependent on degree of containment of esophageal contents and extent of mediastinal contamination; it may be surgical or nonsurgical
• Patients with esophageal perforation or rupture have decreased morbidity and mortality rates if treated within the first 24 hours

Pitfalls

• Lack of physician experience with this condition (owing to its rarity) along with the diversity of clinical symptoms may delay diagnosis, increasing the risk of morbidity and mortality ²

Terminology

Clinical Clarification

• Esophageal perforation or rupture is a life-threatening condition in which the cervical, thoracic, or intra-abdominal esophageal sections are perforated or ruptured iatrogenically, during trauma, spontaneously, or through the ingestion of foreign bodies ³
• May result in the esophageal contents passing into the mediastinum, pleural cavity, and peritoneum
• A hallmark symptom is the dissection of air along the subcutaneous planes or into the mediastinum as identified by radiography in up to 90% of cases ³

Classification

• Classified by cause of perforation or rupture
  • Iatrogenic ⁴
    • Most common (up to 70% of all cases ⁵)
    • Most common sites of iatrogenic esophageal perforation are at anatomically narrowing zones, such as the cricopharyngeal region of the cervical esophagus and the lower esophageal sphincter
  • Spontaneous ³
    • Commonly affects the left posterolateral wall of the lower third of the esophagus 2 to 3 cm proximal to the gastroesophageal junction
    • Usually associated with intense retching and vomiting
    • Represents 15% of cases ⁶
  • Foreign bodies ¹
    • Can partially or completely lacerate the anatomic narrowing of the esophagus
  • Trauma
    • Such as blunt trauma or gunshot wound

Diagnosis

Clinical Presentation

History

• Cervical perforation ⁷
  • Cervical pain (90%)
  • Classically associated with dysphagia and/or odynophagia that worsens with neck flexion and swallowing; dysphonia may also be noted
• Thoracic perforation ⁷
  • Thoracic pain (79%); usually lateralizes to side of perforation
  • Vomiting (84%)
  • Dyspnea (53%)
  • Epigastric pain (47%)
  • Dysphagia (21%)
    • Mackler triad (thoracic pain, vomiting, subcutaneous emphysema) is highly suggestive of the condition but is present in fewer than one-third of cases
• Abdominal perforation ⁷
  • Dorsal pain (worsened by lying on the back) or epigastric pain radiating to the back or scapula (due to diaphragmatic irritation)
• Other reported associated symptoms include:
  • Hematemesis (8%) ⁸
  • Fever (44%) ⁸

Physical examination ³

• Patients are typically in distress ¹
• Emphysematous crepitus is evident in 60% and 30% of patients with cervical and thoracic esophageal perforations, respectively ¹
  • Systolic crunching sound (Hamman sign) may be detectable over the cardiac apex
• Systemic inflammatory response may develop depending on length of time since perforation and the degree of contamination, with signs including the following:
  • Fever (over 38.5 °C); detected in approximately 51% of cases
  • Tachycardia is common
  • Tachypnea
  • Hemodynamic instability
• Left-sided pleural effusion may be present with distal thoracic esophageal perforation/rupture causing dullness to percussion over the involved area ⁹
  • Right-sided pleural effusion is associated with more proximal perforation/rupture

Causes and Risk Factors

Causes

• Iatrogenic esophageal perforation/rupture accounts for up to 70% of cases and results from: ^10 11
  • Endoscopic procedures
    • Occurs at a rate of approximately 0.03% of cases using a flexible endoscope and 0.11% with a rigid scope
    • 1% to 6% risk for endoscopic variceal sclerotherapy
  • Esophageal dilation for strictures and achalasia
    • Risk of 0.5% for esophageal dilation, increasing to 1.7% for dilation for achalasia
  • Surgery on tissue in close proximity to the esophagus
    • Increased risk with certain procedures (eg, mediastinal surgery, cervical spine surgery, thyroidectomy)
  • Transesophageal echocardiography
    • 0.1% to 0.3% risk
• Spontaneous rupture, also known as Boerhaave syndrome, occurs in the absence of preexisting pathology (15% of cases) ¹
  • Typically results from intense vomiting or severe retching
• Foreign objects or trauma ¹
  • Perforation tends to occur where there is anatomic esophageal narrowing:
    • Cricopharyngeus muscle (level of C5-C6)
    • Left main-stem bronchus
    • Aortic arch
    • Lower esophageal sphincter
  • Swallowed foreign bodies account for 80% of cervical perforations ⁷
    • Materials that were inappropriately ingested (eg, metal safety pins)
    • Ingestion of caustic liquids
  • Blunt trauma ¹²
  • External air-blast ⁴
  • Gunshot wounds
• Rarely, esophageal rupture is due to the following:
  • Parturition
  • Weight lifting
  • Status epilepticus
  • Use of Heimlich maneuver

Risk factors and/or associations

Sex

• Esophageal rupture affects men more often than women (55% versus 45%, respectively) ¹⁰

Diagnostic Procedures

Primary diagnostic tools

• Initial diagnosis is clinical and is based on symptoms, signs, and patient history ³
• Lack of physician experience with this condition (owing to its rarity), along with the diversity of clinical symptoms, may delay diagnosis, increasing risk of morbidity and mortality ²
• Begin diagnostic work-up immediately upon clinical suspicion of esophageal rupture ¹
  • Definitive diagnosis is based on radiographic evidence ¹
    • Posteroanterior and lateral plain chest radiography may help diagnose esophageal rupture; it can be done first if diagnosis is uncertain and often is performed first in practice ¹
      • Sufficient for identifying indirect signs of esophageal rupture
      • If patient can swallow, consider using an oral water-soluble contrast medium such as diatrizoate meglumine (Gastrografin)
      • If radiographic evidence is negative and clinical symptoms persist, obtain a CT scan or repeat after 4 to 6 hours
    • CT of the chest and upper abdomen with oral contrast medium is a first line diagnostic tool used to provide both esophageal and extraesophageal information and may be chosen instead of chest radiography ¹
      • Indicated for all patients but especially for those with external trauma, caustic injuries, or critical illness
      • Key examination in patients with suspected perforation or other foreign body–related complications ¹³
    • Esophagram is the second line imaging modality, indicated if CT scan with contrast enhancement is inconclusive ⁸
  • Flexible upper endoscopy is used only when there is a high clinical suspicion of a perforation but radiographic imaging result appears negative/equivocal, or when swallowing contrast media is not an option ¹

Imaging

• Plain chest radiography ⁹
  • May obtain in all patients; add water-soluble contrast medium if needed
  • May show indirect signs of esophageal rupture that include the following:
    • Pneumomediastinum diagnosed as
      • Radiolucent outline around the heart and mediastinum
    • Subcutaneous emphysema diagnosed as
      • Radiolucent striation
    • Pneumothorax and lung collapse diagnosed as
      • Air in the pleural space
      • A shift of the mediastinum
    • Hemothorax diagnosed as
      • Partial or complete opacification of the hemithorax
    • Pleural effusion
• CT of the chest and upper abdomen with oral contrast medium is best imaging procedure ^1 13
  • May be used as first line instead of chest radiography or if chest radiography is inconclusive
  • Key examination in patients with suspected perforation or other foreign body–related complications ¹³
  • Diagnostic findings of esophageal rupture include the following:
    • Collection of fluid and/or air in the mediastinum
    • Esophageal thickening
• Chest fluoroscopy with a water-soluble contrast medium (esophagram) ¹
  • Second line imaging procedure if chest radiograph and/or CT scan is inconclusive
  • Diatrizoate meglumine (Gastrografin) will show contrast leak in most cases
  • Diagnostic findings of esophageal rupture include contrast medium extravasation accompanied by large pleural effusion
  • Avoid barium sulfate owing to extravasation into mediastinum leading to the following:
    • Fibrosing mediastinitis
    • Long-term presence may make interpretation of future mediastinal imaging difficult
  • 10% false-negative rate ⁹

Procedures

• Insertion of a thin, flexible tube equipped with fiber optics and a camera into the upper gastrointestinal tract to visualize a suspected esophageal rupture
• High suspicion of perforation and negative radiographic findings
• Patient unable to swallow contrast agent
• Esophageal perforation observed with radiographic study
• Hemodynamic instability
• Conversion of small tear to a larger perforation during air insufflation
• Direct visualization of perforation site indicates its location and extent

Differential Diagnosis

Most common

• Acute aortic dissection ¹⁴ (Related: Acute Aortic Syndrome)
  • Patients typically present with sudden, severe pain that may radiate from chest or abdomen to back or extremities; hypertension is present in approximately 75% of cases
  • Differentiate by presentation:
    • Sudden chest or back pain accompanied by at least 1 of the following symptoms:
      • Pulse deficit
      • Aortic regurgitation
      • Neurologic manifestations, including the following:
        • Stroke
        • Spinal cord ischemia
        • Ischemic neuropathy
        • Hypoxic encephalopathy
  • Diagnose radiographically
    • Contrast-enhanced CT of the chest and abdomen is commonly used to detect aortic dissection
    • Bedside transesophageal echocardiogram can be used to diagnose aortic dissection when managing a hemodynamically unstable patient
• Acute pericarditis ¹⁵ (Related: Pericarditis)
  • Differentiate by presentation:
    • Typically sudden-onset, high-intensity pleuritic chest pain that worsens with deep inspiration radiating to the neck and upper limbs
    • Pain worsening in supine position and improving when sitting
    • Pericardial friction rub is useful to discern pericarditis when present (85% of cases at some time during the disease course)
  • Diagnose
    • ECG showing typical changes of diffuse upwardly concave ST-segment elevation with PR depression
    • CT showing the enlargement of the ascending or descending aorta
    • Chest radiograph showing excess fluid in the pericardium; appearance of an enlargement of the heart may occur in the presence of pericardial effusion of more than 200 mL
• Mallory-Weiss tear ¹⁶
  • Longitudinal mucosal laceration (intramural dissection) at the gastroesophageal junction resulting from sudden increase in pressure within the stomach (eg, vomiting) accounts for up to 15% of upper gastrointestinal bleeding cases
  • Differentiate by presentation
    • Acute upper gastrointestinal bleeding accompanied by epigastric or back pain and weakness
  • Diagnose
    • Esophagogastroduodenoscopy facilitates visualizing site of mucosal tear at gastroesophageal junction and allows for treatment at the same time
• Pneumonia (Related: Community-Acquired Pneumonia in Adults)
  • Differentiate clinically
    • Patient presents with fever, cough, pleuritic chest pain, dyspnea, and tachypnea
  • Diagnose
    • Chest radiography facilitates the visualization of airspace opacity, lobar consolidation, or interstitial opacities
    • Sputum and blood culture to identify organism causing the infection
• Myocardial infarction (Related: Acute Coronary Syndromes)
  • Differentiate clinically
    • Initially causes substernal pressure or pain with radiation to neck, lower jaw, or arms; may be precipitated by exertion
      • Often associated with dyspnea, nausea, and diaphoresis
  • Diagnose
    • Typical ECG changes and positive cardiac biomarkers (eg, troponins) diagnose infarction
• Spontaneous pneumothorax
  • Differentiate clinically
    • Sudden onset of pleuritic chest pain and dyspnea
    • Classically occurs in tall, thin males in their teens or twenties; also can occur in patients who smoke and have lung disease
    • Findings on examination may include absent tactile fremitus and decreased breath sounds over the involved area of lung
  • Diagnose
    • Plain chest radiograph shows radiolucent air and absence of lung markings in area of collapse

Treatment

Goals

• Prevent further contamination of body cavities with adequate drainage and antibiotics
• Eliminate any focus of infection and inflammation
• Restore alimentary tract continuity
• Establish nutritional support

Disposition

Admission criteria

Esophageal perforation rupture is a medical emergency; admit suspected cases to the hospital immediately

Criteria for ICU admission

• Suspected or confirmed cases of esophageal perforation/rupture require ICU observation and management

Recommendations for specialist referral ³

• Gastroenterology referral/consultation is recommended for all patients with esophageal perforation/rupture
• Thoracic surgical consultation is recommended for all patients with esophageal perforation/rupture, even if nonoperative treatment is chosen
  • If thoracic surgery is not available, transport patient to a facility with available thoracic surgery as soon as possible ¹

Treatment Options

Begin empiric broad-spectrum antibiotic coverage for anaerobes and both gram-negative and gram-positive aerobes when diagnosis is first suspected ⁵

Typically, cervical esophageal perforation is managed by placement of a drain alone; thoracic or abdominal perforation involves more contamination and is more difficult to contain, requiring surgical management ⁹

• Endoscopy is sometimes used to repair a perforation if treated immediately

Surgical treatment

• Gold standard of treatment for patients with early diagnosis (within 24 hours) of unconfined cervical, thoracic (especially when greater than 6 cm in length ¹⁸), and abdominal esophageal perforations ¹⁷
  • For rapid closure of the esophageal leak and drainage of the mediastinal or pleural collection
  • Immediate parenteral nutrition and broad-spectrum antibiotics are necessary to minimize mediastinitis
  • Necessary for the treatment of clinically unstable patients
  • Specific operative strategies are chosen based on location of injury, presence of underlying esophageal disease, and degree of tissue damage, combined with patient’s overall condition
    • Percutaneous drainage
      • Recommended for patients with cervical perforation or those who seek medical treatment after 48 hours from time of incident
    • Extensive surgical drainage and tube thoracostomy
      • Recommended for patients with thoracic or abdominal perforations to contain leakage into mediastinum; occasionally required for cervical esophageal perforation
      • As a general principle, all thoracic or abdominal esophageal perforations require wide mediastinal drainage by opening the parietal pleura in its entire length of the esophagus
      • Debridement with primary closure with or without inclusion of buttressing with adjacent tissue can be done at this time
    • Primary closure with or without autologous tissue
      • Perforations in cervical esophagus
      • Primary closure can be done with interrupted sutures
      • Feeding jejunostomy and draining gastrostomy for nutrition and to allow distal drainage
    • Esophagectomy is recommended as a secondary surgical procedure followed by immediate or delayed reconstruction ⁵
      • Indicated to close an esophageal rupture that was not closed during primary surgery owing to severe mediastinitis or underlying esophageal pathology
      • Immediate reconstruction is indicated when pathologic process is a localized resectable cancer or an undilatable or malignant stricture reconstruction
      • Delayed reconstruction is indicated when there is significant devitalized tissue that does not allow a primary repair (eg, caustic ingestion; when primary repair failed and there is ongoing mediastinal sepsis) ⁸
        • Involves source control by debridement, drainage, and cervical esophagostomy for proximal drainage, and gastrostomy for distal drainage with feeding jejunostomy for nutritional support
    • Esophageal T-tube ⁹
      • For patients with thoracic or abdominal perforations who are hemodynamically unstable
      • Indicated for patients whose perforation cannot be repaired with primary closure
      • Delayed presentation of thoracic or abdominal perforation

Endoscopic treatment

• Use of endoscopic treatment is increasing for perforations recognized immediately, not associated with pleural or mediastinal contamination, in clinically stable patients with no signs of sepsis present ^13 19
  • Increasingly used to treat intrathoracic esophageal perforation smaller than 6 cm with immediate placement of esophageal endoscopic clips or stent to close the defect ¹⁸
• Emergent endoscopy (less than 6 hours) is recommended for sharp-pointed objects, batteries, and magnets ¹³
• Endoscopy is not employed in clinically unstable patients

Nonoperative treatment (approximately 25% of cases) ⁹

• Indicated for most patients with cervical esophageal perforation; appropriate for those with the following:
  • Well-contained perforation and minimal mediastinal soilage on imaging or endoscopic evaluation ¹⁷
  • Injury limited to the esophageal wall ¹⁷
  • No malignancy, stricture, or obstruction in area of perforation ⁸
  • No evidence of systemic infection ⁸
  • Hemodynamic stability ¹⁷
  • Late presentation (24 hours after incident) but good clinical condition ¹⁷
  • Contained cavity that drains back into esophagus ⁸
  • No perforation into abdominal cavity ⁸
  • No free extravasation of contrast medium into body cavities ⁸
  • Availability of advanced imaging modalities and thoracic surgery
• Nonoperative treatments include the following: ⁹
  • Securing the airway and ordering NPO status
  • Nasogastric suction
  • Pain management with opioid analgesics as needed
  • Broad-spectrum IV antibiotics
  • Proton pump inhibitors
    • Indicated for patients with severe erosive esophagitis, esophageal stricture, or malignancies, and/or those who are experiencing dysphagia
  • Nutritional support
• Patients treated nonoperatively remain NPO for 7 days, after which a meglumine diatrizoate (Gastrografin) swallow radiographic study is obtained ⁸

Drug therapy

• Begin empiric broad-spectrum antibiotic coverage for anaerobes and both gram-negative and gram-positive aerobes when diagnosis is first suspected. ⁵
  • β-lactam antibiotics
    • Cefuroxime
      • Cefuroxime Sodium Solution for injection; Adults: 750 mg IV every 8 hours for 7 to 10 days.
    • Ampicillin
      • Ampicillin Sodium Solution for injection; Adults: 500 mg IV every 8 hours for 7 to 10 days.
  • Nitroimidazole antimicrobial ²⁰
    • Metronidazole
      • Metronidazole Solution for injection; Adults: 500 mg IV every 8 hours for 7 to 10 days.
  • Oxazolidinone antibiotic
    • Linezolid ²¹
      • Linezolid solution for injection; Adults: 600 mg IV every 12 hours.
• Proton pump inhibitors ⁵
  • Pantoprazole
    • Pantoprazole Sodium Solution for injection; Adults: 40 mg IV every 12 hours. Switch to oral therapy when feasible.

Nondrug and supportive care

Nonoperative treatment (approximately 25% of cases) ⁹

• Indicated for most patients with cervical esophageal perforation; appropriate for those with the following:
  • Availability of advanced imaging modalities and thoracic surgery
  • Well-contained perforation and minimal mediastinal soilage ¹⁷
  • No perforation into abdominal cavity ⁸
  • Injury limited to the esophageal wall ¹⁷
  • No malignancy, stricture, or obstruction in area of perforation ⁸
  • No evidence of systemic infection ⁸
  • Uncompromised circulation ¹⁷
  • Late presentation (24 hours after incident) but good clinical condition ¹⁷
  • Contained cavity that drains back into esophagus ⁸
  • No free extravasation of contrast medium into body cavities ⁸
• Supportive care ⁹
  • Securing the airway and ordering NPO status
  • Nasogastric suction
  • Pain management with opioid analgesics as needed
  • Broad-spectrum IV antibiotics
  • Proton pump inhibitors
    • Indicated for patients with severe erosive esophagitis, esophageal stricture, or malignancies, and/or those experiencing dysphagia
  • Nutritional support
• Patients treated nonoperatively remain NPO for 7 days, after which a meglumine diatrizoate (Gastrografin) swallow radiographic study is obtained ⁸

Parenteral nutrition ⁵

• To provide nutrition to patients with a dysfunctional gastrointestinal tract and those who are experiencing dysphagia
• Total parenteral nutrition through a central catheter or indwelling IV line
  • May be customized to individual patient requirements, or a standardized solution may be used
• Transition to oral feeding is varied among patients owing to multiple factors

Procedures

Primary closure with or without anchoring using autologous tissue ³

General explanation

• Surgical closure of the rupture primarily using interrupted sutures
  • Repair can be further stabilized with vascularized autologous tissues (eg, pleural flap, diaphragmatic pedicle graft, omentum onlay graft, rhomboid and latissimus dorsi muscles, intercostal muscles, pericardial fat pad)

Indication

• Perforations without extravasation of contrast medium into surrounding body cavities
• Hemodynamic instability

Contraindications

• Mediastinal sepsis
• Underlying malignancy, stricture, or obstruction at site of perforation

Complications

• Site leakage

Tube thoracostomy and surgical drainage (thoracotomy) ²²

General explanation

• A chest tube is inserted into the pleural space and placed to suction (tube thoracostomy)
• In general, all thoracic or abdominal esophageal perforations require wide mediastinal drainage by opening the parietal pleura in its entire length of the esophagus
• Tube placement and surgical drainage (thoracotomy) are typically carried out at the same time; in the absence of cancer or an irreversible distal obstruction, meticulous repair of an intrathoracic esophageal perforation is the preferred approach, regardless of the duration of the injury ²³

Indication

• Thoracic or abdominal perforations (to contain leakage into mediastinum)
• Cervical perforation only if the patient’s pleural effusion becomes grossly contaminated and/or the perforation/rupture remains unconfined after initial percutaneous drainage and nonoperative treatments have been done

Contraindications

• Cervical perforation in a stable patient

Complications

• Bleeding or hemothorax
• Perforation of internal organs
• Intercostal neuralgia
• Subcutaneous emphysema
• Pneumonia
• Empyema

Esophagectomy ⁵

General explanation

• Partial or full surgical removal of the esophagus, with concurrent reconstruction from sections of the stomach or the large intestine

Indication

• Thoracic or abdominal perforations that were not closed during primary surgery owing to severe mediastinitis or underlying esophageal pathology
• Thoracic or abdominal perforations caused by megaesophagus, carcinoma, caustic ingestion, stenosis, or multiple reflux strictures that cannot be dilated

Contraindications

• Hemodynamic stability and perforation/rupture amenable to primary closure
• Hemodynamic instability and perforation/rupture that can be repaired with esophageal T-tube

Complications

• Pneumonia
• Atrial fibrillation
• Recurrent laryngeal nerve injury
• Chyle leak/chylothorax
• Anastomotic leak
• Functional abnormalities (eg, dumping syndrome, reflux)

Esophageal T-tube ¹⁷

General explanation

• The T-tube creates a controlled esophagocutaneous fistula, allowing drainage of the esophagus and time for tissues to heal

Indication

• Hemodynamic instability
• Esophageal injuries that cannot be repaired with primary closure
• Delayed presentation of thoracic or abdominal esophageal perforation

Contraindications

• Perforations caused by megaesophagus, carcinoma, caustic ingestion, stenosis, or multiple undilatable reflux strictures
• Severe mediastinitis or underlying esophageal pathology

Complications

• Leakage
• Atrial fibrillation
• Empyema
• Sepsis
• Chronic fistula formation

Percutaneous drainage ⁹

General explanation

• Recommended to stabilize or minimize leakage into surrounding tissues and mediastinum, and to contain pleural contamination
• Use of fluoroscopy, CT, or ultrasonography to guide needle placement for drainage
• A drainage tube may be inserted until no further drainage is produced

Indication

• Cervical esophageal perforation for patients without sepsis who are hemodynamically stable
• For patients with perforations confined to the mediastinum or who seek medical attention more than 48 hours after the injury

Contraindications

• Gross mediastinum contamination
• Perforations caused by megaesophagus, carcinoma, caustic ingestion, stenosis, or multiple undilatable reflux strictures

Complications ²⁴

• Inadvertent catheterization of adjacent organs
• Vascular fistula formation
• Pseudoaneurysm formation
• Infection

Monitoring

• All patients hospitalized with esophageal perforation or rupture require close monitoring for hemodynamic instability and evidence of systemic infection, typically provided in an ICU ⁸
• Before discharge, imaging is repeated (CT, chest radiograph, or esophagram) using oral meglumine diatrizoate (Gastrografin) to test the perforation site ⁵
  • Patients treated nonoperatively are imaged after 7 days without oral intake to determine closure of the perforation before initiating an oral diet ⁸

Complications and Prognosis

Complications

• Complications are reported in approximately 14% of patients with cervical perforation, 39% with thoracic perforation, and 25% with abdominal perforation ³
  • Pneumonia
  • Empyema
  • Esophageal narrowing or stricture
  • Periesophageal abscess
  • Esophageal leakage
  • Mediastinitis
  • Peritonitis
  • Cardiopulmonary collapse
  • Multiorgan failure

Prognosis

• Mortality of esophageal rupture or perforation ranges from 10% to 40% ^25 8 and is improved with early recognition and treatment initiation within 24 hours; ³ treatment begun more than 48 hours after perforation is associated with 40% to 60% mortality ⁵
  • Iatrogenic perforation has lower mortality of 10%, whereas rupture after emesis is associated with mortality of 60% to 70%

Sources

1: Soreide JA et al: Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 19:66, 2011

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