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|Year : 1989 | Volume
| Issue : 4 | Page : 224-5
Spontaneous oesophageal perforation--(a case report).
RR Patankar, PP Madhok
R R Patankar
Source of Support: None, Conflict of Interest: None
Keywords: Case Report, Child, Preschool, Empyema, etiology,Esophageal Perforation, complications,Human, Male,
|How to cite this article:|
Patankar R R, Madhok P P. Spontaneous oesophageal perforation--(a case report). J Postgrad Med 1989;35:224
| :: Introduction|| |
Oesophageal perforation as a cause of empyema thoracis is uncommon. Unlike thoracic or abdominal oesophagus, cervical oesophagus rarely undergoes spontaneous perforation, particularly in the paediatric age group. Insidious presentation of cervical oesophageal perforation, treated conservatively with success is the subject of this case report.
| :: Case report|| |
A 3 year male child was admitted for painful neck movements, fever and dysphagia of 4 days' duration. There was no history of trauma, tuberculosis or of caustic/foreign body ingestion.. Systemic and local (intra-oral) examination did not reveal any cause. X-ray of the neck was normal. The child responded partially to antibiotics and analgesics- An inflammed lump was noticed over the lower side of the right sternomastoid. The child also developed cough with expectoration. X-ray of the chest revealed a pyopneumothorax [Fig. l], which was treated with intercostal drainage. However, the intercostal drain continued to drain about 50-60 ml of pus per day and also curdled milk. The child remained persistently toxic. On a suspicion of an oesophageal leak, a dye study was carried out, which revealed a perforated cervical oesophagus leaking into the right hemithorax. [Figure - 2] Re-evaluation of the history did not reveal anything suspicious. Endoscopy was negative. An additional intercostal tube was introduced in the second anterior space and through it a Ryle's tube was negotiated into the stomach. Feedings were given through this trans-oesophageal tube. Within a week, frothing into the intercostal drain stopped. A dye study carried out after 3 weeks did not show any leak. The patient was discharged thereafter.
| :: Discussion|| |
The oesophageal perforations are classified as (i) traumatic, (ii) pathological, and (iii) spontaneous. Traumatic perforation follows instrumentation, dilatation or oesophageal anastomosis. It is a surgical emergency, usually involving the thoracic part of the oesophagus. Though immediate surgical intervention gives better results, late cases can be treated by diversion and drainage;, however, the mortality is high.
Pathological perforations may occur following bouginage in cases of carcinoma or stricture. Inspite of diversion or exteriorization, results have been unsatisfactory. Undoubtedly, the patient's poor general condition contributes to the unsavoury outcome.
Spontaneous perforations largely confine themselves to the abdominal or thoracic oesophagus. Forceful ejection of abdominal contents in an unrelaxed oesophagus against a closed glottis is the mechanism described. The tear thus produced is vertical, akin to the " Mallory-Weiss tear More Details." The patient presents as an emergency and the results of the surgical treatment are usually satisfactory. Cameron et al drew attention to the possibility of conservative treatment, particularly in patients who present late. His criteria for selection were: (i) well-contained leak, (ii) minimal symptoms, (iii) minimal sepsis, and (iv) absence of distal pathology.
In all series reported so far, cervical oesophageal tears were attended by the least mortality.
When we had this case of "spontaneous" perforation, fitting well with Cameron's criteria, we decided to treat the child conservatively. An indwelling, trans-oesophageal tube was used both as a stent as well as for diverted feeding. Empyema was drained. We were encouraged by the response of the patient. It is noteworthy that pharyngooesophagoscopy did not reveal the site of the perforation.
The cause of perforation remained obscure. The inflammatory lump, resulting in torticollis, may be the para-oesophageal abscess, resulting from a minor leak. The lump must have grown adherent to, and dissected its way into the cervical pleura leading to an empyema. No lung pathology was ever noted. Though rare, it might be worthwhile keeping oesophageal perforation in mind, when faced with florrid, intractable or recurrent suppuration of the cervical and thoracic region, especially when no other cause is obvious.
| :: References|| |
|1.||Aird, I.: "Companion in Surgical Studies." 2nd Edition, E. & S. Livingstone, Ltd., Edinburgh and London, 1958, pp. 511-513. |
|2.||Cameron, J. L., Kieffer, R. F., Hendrix T. R., Mehigan, D. G. and Baker, R. R.: Selective non-operative management of contained intrathoracic oesophageal disruptions. Ann. Thorac. Surg., 27: 404-408, 1979. |
|3.||Goldstein, L. A. and Thompson, W. R.: Oesophageal perforations; a 15-year experience. Amer. J. Surg., 143: 495-503, 1982. |
|4.||Postlethwait, R. W.: "Surgery of the Oesophagus." 2nd Edition, Editors: R. W. Postlethwait and W. C. Sealy, Appleton-Century-Crofts, New York, 1979, pp. 161-178. |
|5.||Skinner, D. B., Little, A. G. and De-Meester, T. R.: Management of oesophageal perforation. Amer. J. Surg., 139: 760-764, 1980. |
[Figure - 1], [Figure - 2]