Oesophageal trauma and foreign bodies

Oesophageal perforations are usually the result of forceful vomiting (Boerhaave’s syndrome) or iatrogenic injury, although there are rarer traumatic causes. The diagnosis is usually considered in a patient who develops symptoms after an endoscopic intervention. However, the clinical presentation may not be so obvious for postemetic perforation; a high index of suspicion in unwell patients with appropriate symptoms is required. Investigation by imaging tests (chest radiograph, CT or contrast swallow) and increasingly with the use of endoscopy will confirm the diagnosis. Management is dictated by the patient’s general condition at presentation, the cause and site of the perforation, the presence of underlying oesophageal disease and the degree of contamination. Non-operative treatment may be suitable in stable patients with a contained leak, particularly after iatrogenic injury. The insertion of a covered stent by endoscopy has also been used as primary treatment. For the majority of patients a variety of operative strategies are used. These range from drainage and oesophageal diversion to repair of the perforation or resection of the oesophagus. In view of the significant morbidity and mortality associated with oesophageal perforation, these injuries should be managed in a specialist unit after early referral. Caustic injuries from swallowed acid or alkali are a special cause of oesophageal injury. The chemical burns they produce may cause early perforation or late stricture of the oesophagus. Finally, swallowed foreign bodies are a common clinical problem. Although many may pass spontaneously, some may cause significant injury to the oesophagus from impaction or perforation.