Management of Idiopathic and Iatrogenic Esophageal Perforations.

DA Esophageal perforations can generally be classified as iatrogenic or idiopathic. Iatrogenic perforations are usually caused by gastroenterologists or surgeons performing endoscopy who inadvertently perforate the esophagus over the course of the procedure. Iatrogenic perforations can occur via a variety of other means, including when a nasogastric or feeding tube placement goes wrong or, less commonly, when a cardiologist performs a transesophageal echocardiogram and the probe inadvertently perforates the esophagus. Perforations during surgery are uncommon but have occurred. Idiopathic perforations are not endoscope-based, but are usually caused by severe retching (leading to a tear) or foreign bodies, including trapped food boluses or swallowed sharp objects. Boerhaave syndrome is a spontaneous perforation of the esophagus that results from forceful vomiting and is one of the main causes of idiopathic perforation that I see in my practice. Other causes are foreign objects and food impaction in the esophagus. The most commonly swallowed objects I encounter are toothpicks, sewing needles, and metal dental bridges. Sometimes a person will swallow a piece of meat that becomes trapped (either due to an intrinsic or extrinsic stenosis or a motility disorder such as eosinophilic esophagitis), and it sits in the esophagus long enough to wear down the esophageal wall and break through. G&H How is Boerhaave syndrome diagnosed, and how should it be treated?