Oesophagus – Perforation, Mallory Weiss Syndrome and Corrosive Injury

Dr. Vivek ShrihariAssistant Professor

Department of General SurgeryMGMCRI, Puducherry

Oesophageal Perforation

• Etiology:• This may be caused by swallowed foreign

bodies or corrosives, rupture at oesophagoscopy, dilatation or biopsy, penetrating wound, or following a violent vomit after a large meal (Boerhaave’s syndrome).

Symptoms and signs:

• History of foreign body• Corrosive ingestion• Endoscopy• Violent vomit• Sudden or gradual onset of pain in chest, neck

and upper abdomen• Dysphagia, Pyrexia, Shock, Cyanosis, Surgical

Emphysema in suprasternal notch

Investigations:

• CXR: air in neck and mediastinum, pleural effusion

• Gastrograffin swallow (not Barium) will confirm the diagnosis and demonstrate the site.

Complication:

Treatment:

• Broad-spectrum antibiotics• Small perforations may be treated expectantly

with I.V. fluids, nil orally• Large perforations require surgical repair and

drainage of the area.

Mallory-Weiss Syndrome

• Etiopathogenesis:• Forceful vomiting producing a mucosal tear at the

cardia; not a full perforation• Vigorous vomiting producing a vertical split in the

mucosa• In 90% cases, occurs immediately below the SC

junction at the cardia• Only 10% tears seen in the oesophagus• Alcohol

Clinical Features:

• Haematemesis - usually not severe• Chest pain• Odynophagia• Dysphagia

Investigations:

• Routine blood and urine investigations• Endoscopy• Contrast Radiology – Barium/Gastrograffin

studies

• Intramural Rupture• Intramural Haematoma

Treatment:

• Endoscopic injection therapy in severe cases of haematemesis

• Surgery rarely required• Conservative management• Symptoms usually resolve in 1-2 weeks.• Orals can be started as soon as the symptoms

allow.

Corrosive Oesophagitis

• Etiopathogenesis:• The accidental or deliberate ingestion of

corrosives causes severe oesophagitis.• Common substances – caustic soda, bleach

and sulphuric acid• Extensive damage to the mouth, pharynx,

larynx, stomach and oesophagus

Symptoms and signs:

• History of ingestion• Burning pain from mouth to stomach• Fever• Shock• Respiratory distress if the patient has

aspirated• Oedema of lips, lungs, pharynx

Investigations:

• Routines• Contrast Radiography• Early endoscopy with fine fibreoptic

endoscope to assess degree of damage.

Complications:

• Bleeding• Perforation• Stricture – a late complication

Treatment:

• Emergency• Dilute acid (vinegar) or alkali (sodium

bicarbonate) may be used to neutralize the ingested substance.

• Never induce vomiting. It may rupture the already damaged oesophagus.

• Medical Broad-spectrum antibiotics, Steroids, TPN

• Endoscopic dilatation of strictures Gentle dilatation may be done at 3-4 weeks.

• Surgery If a severe stricture develops, oesophageal replacement by interposition of a segment of colon is required.

• Stomach may also be used if it has been spared from the effects of caustic injury.

• Surgery may also be required if perforation occurs.

Prognosis:

• Appropriate early treatment of caustic burns usually gives good results.

• Extensive burns with strong acids or strong alkalis progress to stricture formation and require surgery.