Suspected Esophageal Perforation
Chest/epigastric pain after vomiting, endoscopy, or foreign body
All Pathways
Cardiothoracic SurgeryEmergency
Esophageal Perforation / Boerhaave Syndrome (WSES 2019)
Esophageal Perforation / Boerhaave Syndrome (WSES 2019): Suspected Esophageal Perforation → Clinical Recognition → Diagnostic Workup (WSES Level I) → Id...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Action Clinical Recognition
Mackler Triad and other signs
- MACKLER TRIAD:
- • Vomiting
- • Chest pain
- • Subcutaneous emphysema
- Other signs: fever, dysphagia, odynophagia
- Hamman sign (mediastinal crunch)
- Pleural effusion (often left-sided)
03Action Diagnostic Workup (WSES Level I)
Confirm diagnosis and localize perforation
- Labs: CBC, BMP, lactate, CRP (WSES Level I)
- Imaging sequence:
- 1. CXR: pneumomediastinum, pleural effusion, hydropneumothorax
- 2. Water-soluble contrast swallow (Gastrografin)
- 3. CT chest/abdomen with oral contrast (most sensitive)
- CT sensitivity >90% for perforation
04Action Identify Etiology
Guides management approach
- SPONTANEOUS (Boerhaave): 15%
- • Post-vomiting, large tear (3-8cm)
- • Usually left lower esophagus
- IATROGENIC: 60%
- • Endoscopy, dilation, TEE
- • Often smaller, better contained
- TRAUMA/FOREIGN BODY: 25%
05Decision Management Approach?
Based on clinical status and leak containment
- CONSERVATIVE criteria (all must be met):
- • Well-contained leak (no mediastinal soiling)
- • Drains back into esophagus
- • Minimal symptoms
- • No sepsis
06Action Conservative Management
For contained perforations, minimal contamination
- NPO, NG tube
- Broad-spectrum IV antibiotics
- Antifungals (consider)
- PPI therapy
- TPN for nutrition
- Serial imaging to confirm healing
- Consider endoscopic stent if:
- • Small contained perforation
- • No sepsis
07Action Endoscopic Options
Emerging alternatives
- Self-expanding stents (SEMS):
- • Bridge to healing or surgery
- • Best for contained leaks
- Endoscopic vacuum therapy (EVT):
- • Newer technique, promising results
- • Multicenter data emerging (2025)
- Clips/over-the-scope clips (OTSC):
- • Small acute perforations
08Action ICU Care & Monitoring
Ongoing management
- Sepsis management
- Nutrition (TPN → enteral via J-tube)
- Repeat imaging in 5-7 days
- Contrast swallow before oral intake
- Watch for: empyema, abscess, fistula
09Outcome Healed / Reconstructed
Long-term: stricture surveillance
- Path rejoins step 08Shared downstream outcome
10Action Surgical Intervention
For uncontained leaks, sepsis, or failed conservative
- TIMING CRITICAL:
- • <24h: primary repair possible
- • >24h: tissue friable, drainage/diversion
- Approach: left thoracotomy (distal)
- or right thoracotomy (mid/proximal)
11Action Surgical Options
Based on tissue quality and timing
- PRIMARY REPAIR (<24h, healthy tissue):
- • Debride edges, 2-layer closure
- • Buttress with pleural/intercostal flap
- • Wide drainage
- DRAINAGE ONLY (>24h or septic):
- • Decortication, drain mediastinum
- • Consider T-tube
- DIVERSION (severe contamination):
- • Cervical esophagostomy
- • Gastrostomy + feeding jejunostomy
- • Delayed reconstruction
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 10Shared downstream outcome
12Warning ⚠️ TIME IS CRITICAL
Mortality: <24h = 10-25%, >24h = 40-60%, untreated = nearly 100%
Guideline Source
WSES Guidelines on Esophageal Emergencies
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Mortality 60% if delayed diagnosis, nearly 100% untreated
- Optimal management depends on time to diagnosis
- Endoscopic stenting role still evolving
- Decision to repair vs drain vs divert depends on tissue quality
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Esophageal Perforation / Boerhaave Syndrome (WSES 2019)?
The Esophageal Perforation / Boerhaave Syndrome (WSES 2019) is a emergency clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES Guidelines on Esophageal Emergencies.
What guideline is the Esophageal Perforation / Boerhaave Syndrome (WSES 2019) based on?
This algorithm is based on WSES Guidelines on Esophageal Emergencies (DOI: 10.1186/s13017-019-0245-2).
What are the limitations of the Esophageal Perforation / Boerhaave Syndrome (WSES 2019)?
Known limitations include: Mortality 60% if delayed diagnosis, nearly 100% untreated; Optimal management depends on time to diagnosis; Endoscopic stenting role still evolving; Decision to repair vs drain vs divert depends on tissue quality. Individual patient factors may require deviation from these recommendations.
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