Delos Reyes Arthur P, Clancy Christopher, Lach Joseph, Olorunto William A, Williams Mallory
University of Toledo Medical Center, 3000 Arlington Ave, MS 1095, Toledo, OH 43614, United States.
Int J Surg Case Rep. 2013;4(6):550-3. doi: 10.1016/j.ijscr.2013.02.009. Epub 2013 Feb 24.
Esophageal perforation in the setting of blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms accompanied by distracting injury.
We present a case of esophageal perforation resulting from a fall from height. Unexplained air in the soft tissues planes posterior to the esophagus as well as subcutaneous emphysema in the absence of a pneumothorax on CT aroused clinical suspicions of an injury to the aerodigestive tract. The patient suffered multiple injuries including bilateral first rib fractures, C6 lamina fractures, C4-C6 spinous process fractures, a C7 right transverse process fracture with associated ligamentous injury and cord contusion, multiple comminuted nasal bone fractures, and a right verterbral artery dissection. Esophageal injury was localized using a gastrograffin esophagram to the cervical esophagus and was most likely secondary to cervical spine fractures. Because there were no clinical signs of sepsis and the esophagram demonstrated a contained rupture, the patient was thought to be a good candidate for a trial of conservative management consisting of broad spectrum intravenous antibiotics, oral care with chlorhexadine gluconate, NPO, and total parenteral nutrition. No cervical spine fixation or procedure was performed during this trial of conservative management. The patient was received another gastrograffin esophagram on hospital day 14 and demonstrated no evidence of contrast extravasation.
Early diagnosis and control of the infectious source are the cornerstones to successful management of esophageal perforation from all etiologies. Traditionally, esophageal perforation relied on a high index of clinical suspicion for early diagnosis, but the use of CT scan for has proved to be highly effective in diagnosing esophageal perforation especially in patients with atypical presentations. While aggressive surgical infection control is paramount in the majority of esophageal perforations, a select subset of patients can be successfully managed non-operatively.
In the setting of blunt trauma, esophageal perforation is rare and is associated with a high morbidity. In select patients who do not show any clinical signs of sepsis, contained perforations can heal with non-operative management consisting of broad spectrum antibiotics, strict oral hygiene, NPO, and total parenteral nutrition.
钝性创伤导致的食管穿孔较为罕见，由于伴有其他易分散注意力的损伤，其非典型的体征和症状使得诊断颇具难度。
我们报告一例因高处坠落导致食管穿孔的病例。CT显示食管后方软组织平面出现不明原因的气体以及皮下气肿，且无气胸，这引起了对气道消化道损伤的临床怀疑。患者还遭受了多处损伤，包括双侧第一肋骨骨折、C6椎板骨折、C4 - C6棘突骨折、C7右侧横突骨折伴相关韧带损伤及脊髓挫伤、多处粉碎性鼻骨骨折以及右侧椎动脉夹层。通过泛影葡胺食管造影将食管损伤定位至颈段食管，最可能继发于颈椎骨折。由于没有脓毒症的临床体征且食管造影显示为局限性破裂，该患者被认为是保守治疗试验的合适人选，保守治疗包括静脉输注广谱抗生素、用葡萄糖酸氯己定进行口腔护理、禁食以及全胃肠外营养。在此次保守治疗试验期间未进行颈椎固定或手术。患者在住院第14天接受了另一次泛影葡胺食管造影，结果显示无造影剂外渗迹象。
早期诊断和控制感染源是成功治疗各种病因导致的食管穿孔的基石。传统上，食管穿孔依赖于高度的临床怀疑以进行早期诊断，但事实证明，CT扫描在诊断食管穿孔方面非常有效，尤其是对于表现不典型的患者。虽然在大多数食管穿孔病例中积极的手术控制感染至关重要，但一小部分患者可以通过非手术成功治疗。
在钝性创伤情况下，食管穿孔罕见且发病率高。对于未表现出任何脓毒症临床体征的特定患者，局限性穿孔可通过包括广谱抗生素、严格口腔卫生、禁食和全胃肠外营养的非手术治疗实现愈合。
