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BMJ Case Rep. 2010; 2010: bcr01.2009.1506.
Published online 2010 January 13. doi:  10.1136/bcr.01.2009.1506
PMCID: PMC3028187
Rare disease

Unusual simultaneous multifocal rupture of oesophagus, stomach and diaphragm after blunt trauma

Abstract

An unusual case of simultaneous multifocal rupture of the oesophagus, stomach and diaphragm after blunt trauma is described. The characteristic computed tomography scans (with intraluminal contrast application) of the ruptured oesophagus are shown, and successful management is presented.

Background

Thoracic oesophageal rupture caused by blunt trauma is a very rare injury with an incidence of 0.001%.1 Such cases have been reported in the trauma literature fewer then 20 times. Non-penetrating traumatic perforation of the distal part of the oesophagus is uncommon, compared with iatrogenic injuries in the upper oesophageal region. Usually the diagnosis of damage to the oesophagus is delayed or missed, which contributes to the high rate of mortality (20–30%) for oesophageal perforation.1,2 The coincidence of the rupture of the oesophagus, stomach and diaphragm poses substantial diagnostic and therapeutic challenges for the surgeon.

Case presentation

After a motor vehicle accident a 19-year-old man was transferred to our trauma department from a local hospital. The car driven by the victim had rolled over at a high speed; seat belts were used. At admission the patient presented with unconsciousness (Glasgow Coma Scale 9), shock (systolic blood pressure 60 mm Hg), and tachycardia (140 beats/min.). Both pleural cavities were drained in the emergency department because of haemopneumothorax caused by ribs fractures. No further examination of the obtained fluid has been performed as there was no suspicion of oesophageal rupture, and ribs fractures seemed to be the cause of haemopneumothorax. Nevertheless, testing for amylase would have been of value. Computed tomography (CT) scans confirmed the diagnosis in the thorax and showed some fluid in the peritoneal cavity and pelvic fracture. Laparotomy was performed which revealed 500 ml of blood in the peritoneal cavity and a grade II (American Association for the Surgery of Trauma) spleen injury. The spleen was preserved after the haemorrhaging was stopped. A left sided retroperitoneal haematoma was found and not explored.

After surgery the patient was admitted to the intensive care unit. Broad spectrum antibiotics and fluids were given intravenously. However, the patient remained unstable and drugs such as inotropes and colloids were needed. The next day (18 h after admission) another CT scan with contrast administered through a gastric catheter showed some fluid around the spleen. Leakage of the oesophagus to the left pleural cavity was shown. The patient had leucocytosis and fever, and a procalcitonin test was positive.

The patient was taken to the operating room where a posterolateral thoracotomy was performed. In patients with multiple trauma, especially after traffic accidents, an inspection of the abdominal cavity is required even if preoperative diagnosis suggests particular organ damage. That is why even if the diagnosis has been made preoperatively, a posterolateral thoracotomy together with a laparotomy would have been undertaken in order to gain full access to the abdominal cavity and check all the organs. A 15 cm long traumatic rupture of the diaphragm that affected the oesophageal hiatus was found. The diaphragmatic rupture was filled by pressure from the stomach. The conjunction area showed two perforations situated opposite each other; a longer one (10 cm) starting from the lower oesophagus and extending to the stomach fundus by a greater curvature, and a shorter perforation (5 cm) extending from the oesophagus to the gastric cardia by a lesser stomach curvature. The left pleural cavity contained 1000 ml of blood, mixed with some food which was evacuated. The oesophagus and stomach were sutured (two layers) and the diaphragm was reconstructed by single sutures (fig 1). Drains were put into the mediastinal and pleural spaces. No contamination or blood in the peritoneal cavity was found during regular re-laparotomy.

Figure 1
Upper panels: computed tomography scans revealing leakage of contrast from the lower part of the oesophagus to the left pleural cavity. Lower panels: intraoperative photographs showing primary reconstruction of oesophagus and stomach perforations.

Outcome and follow-up

The postoperative course was uneventful. Parenteral nutrition lasted for 10 days. The gastric tube was removed after 4 days, and nutrition by mouth started after 7 days. Antibiotic treatment was continued for 6 days. Two weeks after surgery an x-ray with contrast revealed no leakage, and 4 weeks later the patient was doing well with no digestive complaints. A follow up chest x-ray showed no pathology. The patient left hospital in good condition 16 days after admission.

Discussion

Oesophageal ruptures are caused most commonly by an iatrogenic mechanism (55%), spontaneous rupture (35%), foreign body damage (7.5%) or traumatic rupture (1–2%).2 Traumatic injury of the oesophagus after blunt thoracic trauma is very rare. Also, traumatic oesophageal rupture combined with lesions in other structures is unusual. We managed to find in the literature only synchronous duodenal perforation combined with diaphragmatic rupture.3,4 The main mechanism of these injuries is uncertain, but it might be similar to that in Boerhaave’s syndrome—that is, high intraluminal pressure that is generated suddenly during the accident causes ruptures. We hypothesise that the pathogenic mechanism of the presented case was blunt trauma and deceleration, which led to a sudden increase in intra-abdominal and intraluminal pressures. During the thoracotomy we found “old” and “new” parts of the herniated stomach. The difficulty in diagnosing ruptured organs is partly due to the lack of specific symptoms. In the present case a delayed diagnosis was caused by the absence of stomach fluid and food fragments in the peritoneal cavity during the first laparotomy. The herniated stomach was closely attached to the diaphragm and associated with retroperitoneal haematoma and haemorrhagic effusions.

Oesophagoscopy and spiral multislice CT confirmed the perforation. CT scans can sensitively detect pneumomediastinum and pneumoperitoneum.5 Clinical symptoms such as pain, dyspnoea, subcutaneous emphysema, and systematic inflammatory response syndrome (SIRS) are typical and non-specific. The classical triad of symptoms including vomiting, chest pain and subcutaneous emphysema is rare. The principles of treatment of these perforations are: gastric decompression, adequate nutrition, wide drainage, and broad spectrum antibiotics. Delayed treatment in oesophageal rupture leads to acute mediastinitis, multiple organ dysfunction, sepsis, and finally death. In the case of oesophageal injury it is of the utmost importance to implement surgery as soon as possible. Conservative treatment may be introduced for cervical and thoracic oesophageal injuries which do not include the pleura. The overall mortality for oesophageal perforation ranges from 20–30%.1,2 We recommend as a rule that oesophageal rupture should be suspected after high energy blunt trauma. In cases with radiologically diagnosed oesophageal leakage, during the operation the surgeon should search for one or more perforation site, because delay is dangerous for the patient.

Learning points

  • If you recognise one traumatic injury of the upper gastrointestinal tract you have to search for another.
  • A second laparotomy after damage control is the most important medical procedure for the patient’s survival.
  • Do everything quick, but not too quick; remember that you have to careful.

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Monzon JR, Ryan B. Thoracic esophageal perforation secondary to blunt trauma. J Trauma 2000; 49: 1129–31. [PubMed]
2. Beal SL, Pottmeyer EW, Spisso JM. Oesophageal perforation following external blunt trauma. J Trauma 1988; 28: 1425–32. [PubMed]
3. Altorjay A, Szilagyi A, Sarkany A, et al. Synchronous spontaneous perforation of the oesophagus and duodenal ulcer. Dis Esophagus 2005; 18: 207–10. [PubMed]
4. Maslov VI, Takhtamysh MA. Surgical policy in complicated traumatic diaphragmatic hernias. Khirurgiia 2004; 7: 26–31. [PubMed]
5. De Lulio di Castelguidone E, Pinto A, Merola S, et al. Role of spiral and multislice computed tomography in the evaluation of traumatic and spontaneous oesophageal perforation. Our experience. Radiol Med 2005; 109: 252–9. [PubMed]

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