Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 1832  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
 :: Next article
 :: Previous article 
 :: Table of Contents
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::Related articles
 ::  [PDF Not available] *
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  References
 ::  Article Figures

 Article Access Statistics
    Viewed4453    
    Printed80    
    Emailed0    
    PDF Downloaded0    
    Comments [Add]    

Recommend this journal


 


 
Year : 1989  |  Volume : 35  |  Issue : 4  |  Page : 224-5

Spontaneous oesophageal perforation--(a case report).




Correspondence Address:
R R Patankar


Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 0002641525

Rights and PermissionsRights and Permissions



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

How to cite this URL:
Patankar R R, Madhok P P. Spontaneous oesophageal perforation--(a case report). J Postgrad Med [serial online] 1989 [cited 2020 Feb 22];35:224. Available from: http://www.jpgmonline.com/text.asp?1989/35/4/224/5678





 :: Introduction Top


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 Top


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 Top


The oesophageal perforations are classified as (i) traumatic, (ii) pathological, and (iii) spontaneous.[1] 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;[5], 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.[3] 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[2] 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.[4]

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 Top

1.Aird, I.: "Companion in Surgical Studies." 2nd Edition, E. & S. Livingstone, Ltd., Edinburgh and London, 1958, pp. 511-513.  Back to cited text no. 1    
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.  Back to cited text no. 2    
3.Goldstein, L. A. and Thompson, W. R.: Oesophageal perforations; a 15-year experience. Amer. J. Surg., 143: 495-503, 1982.  Back to cited text no. 3    
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.  Back to cited text no. 4    
5.Skinner, D. B., Little, A. G. and De-Meester, T. R.: Management of oesophageal perforation. Amer. J. Surg., 139: 760-764, 1980.  Back to cited text no. 5    


    Figures

[Figure - 1], [Figure - 2]



 

Top
Print this article  Email this article
Previous article Next article
Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow