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Unique case of esophageal rupture after a fall from height
- Mark van Heijl†1Email author,
- Teun P Saltzherr†1,
- Mark I van Berge Henegouwen1 and
- J Carel Goslings1
© van Heijl et al; licensee BioMed Central Ltd. 2009
Received: 16 June 2009
Accepted: 15 December 2009
Published: 15 December 2009
Traumatic ruptures of the esophagus are relatively rare. This condition is associated with high morbidity and mortality. Most traumatic ruptures occur after motor vehicle accidents.
We describe a unique case of a 23 year old woman that presented at our trauma resuscitation room after a fall from 8 meters. During physical examination there were no clinical signs of life-threatening injuries. She did however have a massive amount of subcutaneous emphysema of the chest and neck and pneumomediastinum. Flexible laryngoscopy revealed a lesion in the upper esophagus just below the level of the upper esophageal sphincter. Despite preventive administration of intravenous antibiotics and nutrition via a nasogastric tube, the patient developed a cervical abscess, which drained spontaneously. Normal diet was gradually resumed after 2.5 weeks and the patient was discharged in a reasonable condition 3 weeks after the accident.
This case report presents a high cervical esophageal rupture without associated local injuries after a fall from height.
Esophageal rupture due to external trauma was first described in 1936 by Vinson. Traumatic ruptures of the esophagus represent 4-14% of all esophageal perforations[2, 3]. Penetrating or iatrogenic trauma (during endoscopy or operation) are the most frequent causes of rupture of the esophagus. Ruptures of the esophagus due to blunt trauma are very rare and are estimated to occur in less than 1% of patients experiencing blunt (cervical) trauma. We present a rare case of cervical esophageal rupture after a high energy trauma due to a fall from the third floor of a building.
Written informed consent was obtained from this patient.
Cervical esophageal rupture due to blunt trauma without associated injuries is very rare. Esophageal rupture is associated with high mortality and morbidity; early diagnosis and subsequent treatment can add to a beneficial outcome[2, 5]. We present a unique report of a case of a high cervical esophageal rupture after a fall from height without associated injuries in the cervical area. Case reports about traumatic esophageal ruptures are not new; however, almost all cases describe motor vehicle accidents [6–15]. Explanation of the trauma mechanism in case reports on cervical esophageal ruptures specifically vary from blunt external trauma, cervical flexion-hyperextension injury to fracture-dislocation of cervical vertebrae [6, 10]. Tracheo-esophageal fistula following a fall of 3 m was reported once, and was surgically repaired. This was however an intrathoracic esophageal rupture located just above the carina and thought to be caused by the esophagus and trachea being crushed between the sternum anteriorly and the vertebral column posteriorly. In our case the trauma-mechanism could not be fully clarified. Because no associated lesions were found in the cervical area, direct blunt trauma is probably not the cause of this rupture. Rupture caused by crush against the cervical spine due to flexion-hyperextension injury has never been described without concomitant cervical spine injury. This leaves an acute rise in intraluminal esophageal pressure as the most probable cause for this rupture.
Another lesson that can be learned from this case is the fact that the leakage was not detected by CT, even after administering oral contrast. Although no specific physical complaints of the injury were present during initial evaluation and the injury itself was not detected on CT high clinical suspicion was raised due to massive subcutaneous emphysema and pneumomediastinum without injury to the trachea, bronchus or lungs on CT and bronchoscopy. This was the main reason to suspect the diagnosis of esophageal rupture, perform laryngoscopy and to start prophylactic antibiotics and conduct further diagnostics, as recommended earlier by Goudarzi et al . Contrast-swallow examination and upper esophageal endoscopy are diagnostic modalities of choice in case of suspicion of esophageal rupture. Delay in diagnosis was introduced in our case because other, potentially disabling injuries required treatment first. However, no adverse effects were encountered; antibiotics were already initiated and oral nutrition prohibited.
Depending on the cause and site of a rupture, treatment is either conservative or interventional. Interventional treatment options consist of surgical repair, esophageal resection, exclusion and diversion of the esophagus and chest drainage with or without repair. However, interventional treatment is more frequently required in intrathoracic ruptures. In general, most cervical esophageal perforations unlike intrathoracic perforations can be treated conservatively, especially if the leak is contained and clinical signs are mild. Conservative treatment consists of fluid resuscitation, antibiotics, gastric decompression and food restriction. It is reported that 80% of the conservatively treated high esophageal ruptures will heal successfully. In case of contained leakage it is most unlikely that secondary life-threatening complications like mediastinitis develop, which justifies our policy in this case.
This case report presents a high cervical esophageal rupture without associated local injuries after a fall from height. As with any other cervical esophageal perforations, early recognition and treatment are of great importance. This case supports the selective non-surgical treatment policy for cervical perforations.
- Vinson PP: External trauma as a cause of lesions of the oesophagus. Am J Digest Dis Nutr. 1936, 3: 457-9.View ArticleGoogle Scholar
- Eroglu A, Can KI, Karaoganogu N, Tekinbas C, Yimaz O, Basog M: Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus. 2004, 17 (1): 91-4. 10.1111/j.1442-2050.2004.00382.x.View ArticlePubMedGoogle Scholar
- Gupta NM, Kaman L: Personal management of 57 consecutive patients with esophageal perforation. Am J Surg. 2004, 187 (1): 58-63. 10.1016/j.amjsurg.2002.11.004.View ArticlePubMedGoogle Scholar
- Kuhlman JE, Pozniak MA, Collins J, Knisely BL: Radiographic and CT findings of blunt chest trauma: aortic injuries and looking beyond them. Radiographics. 1998, 18 (5): 1085-106.View ArticlePubMedGoogle Scholar
- Bernard AW, Ben-David K, Pritts T: Delayed presentation of thoracic esophageal perforation after blunt trauma. J Emerg Med. 2008, 34 (1): 49-53. 10.1016/j.jemermed.2007.03.016.View ArticlePubMedGoogle Scholar
- Bahadursingh AM, Longo WE: Blunt traumatic rupture of the cervical esophagus. J Trauma. 2006, 61 (6): 1543-4. 10.1097/01.ta.0000249967.92108.2e.View ArticlePubMedGoogle Scholar
- Carter MP, Long RF, Pellegrini RA, Wynn RA: Traumatic esophageal rupture: unusual cause of acute mediastinal widening. South Med J. 1991, 84 (6): 767-9.View ArticlePubMedGoogle Scholar
- Cordero JA, Kuehler DH, Fortune JB: Distal esophageal rupture after external blunt trauma: report of two cases. J Trauma. 1997, 42 (2): 321-2. 10.1097/00005373-199702000-00026.View ArticlePubMedGoogle Scholar
- Fernandez-Llamazares J, Moreno P, Garcia F, Mira X, Catalan R, De la CJ: Total rupture of the gastro-oesophageal junction after blunt trauma. Eur J Surg. 1999, 165 (1): 73-4. 10.1080/110241599750007540.View ArticlePubMedGoogle Scholar
- Goudarzi HA, Hall WW, Mason LB: Rupture of the cervical esophagus from blunt trauma. South Med J. 1983, 76 (12): 1563-4.View ArticlePubMedGoogle Scholar
- Micon L, Geis L, Siderys H, Stevens L, Rodman GH: Rupture of the distal thoracic esophagus following blunt trauma: case report. J Trauma. 1990, 30 (2): 214-7. 10.1097/00005373-199002000-00015.View ArticlePubMedGoogle Scholar
- Sartorelli KH, McBride WJ, Vane DW: Perforation of the intrathoracic esophagus from blunt trauma in a child: case report and review of the literature. J Pediatr Surg. 1999, 34 (3): 495-7. 10.1016/S0022-3468(99)90511-0.View ArticlePubMedGoogle Scholar
- Smock ED, Andrew A: A case of traumatic rupture of the distal oesophagus: the importance of early diagnosis. Eur J Emerg Med. 2008, 15 (2): 95-6. 10.1097/MEJ.0b013e3280ef6953.View ArticlePubMedGoogle Scholar
- Stothert JC, Buttorff J, Kaminski DL: Thoracic esophageal and tracheal injury following blunt trauma. J Trauma. 1980, 20 (11): 992-5. 10.1097/00005373-198011000-00018.View ArticlePubMedGoogle Scholar
- Young CP, Large SR, Edmondson SJ: Blunt traumatic rupture of the thoracic oesophagus. Thorax. 1988, 43 (10): 794-5. 10.1136/thx.43.10.794.View ArticlePubMedPubMed CentralGoogle Scholar
- Elliott M, Brady P, Smith R: Tracheo-oesophageal fistula following a fall. ANZ J Surg. 2001, 71 (12): 772-3. 10.1046/j.1445-1433.2001.02260.x.View ArticlePubMedGoogle Scholar
- Young CA, Menias CO, Bhalla S, Prasad SR: CT features of esophageal emergencies. Radiographics. 2008, 28 (6): 1541-53. 10.1148/rg.286085520.View ArticlePubMedGoogle Scholar
- Triggiani E, Belsey R: Oesophageal trauma: incidence, diagnosis, and management. Thorax. 1977, 32 (3): 241-9. 10.1136/thx.32.3.241.View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/9/24/prepub
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