Treatment of disorder
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medical treatment
Disease where all layer of esophageal wall is raptured, or perforation is developed by sudden internal pressure raise on normal esophagus with no psychogenic pain. This is reported firstly by Boerhaave in 1724, and this disease is relatively rare case. Early diagnosis and early treatment is extremely crucial for this disease, and by delayed initial diagnosis, infectious complicating disease (thoracic empyema, longitudinal abscess) lead to serious condition and prognosis is getting worse. It is necessary to always bear in mind that this is the important disease in Emergency Surgical region. Life-saving rate exceeds more than 90% by early diagnosis and active surgery, but in case it has taken more than 12 hours to the treatment due to the delayed diagnosis by the lower recognition, death rate rises up to 50%.
Vomiting after alcoholic drink is considered as contributing factor and common among 30s to 50s male. Esophagus is longitudinally ruptured with having pressure from normal gastric and esophageal junction area to lower esophagus. Favorite site is lower esophagus left wall. This is because, muscle layer at lower esophagus wall is thin compared with stomach muscle layer, pectinate defect on ring-shaped muscle can be seen occasionally, so that congenitally brittle part is developed due to the progression of nerve vessel from outside of wall. Also, anatomical aspect can be considered as a cause where only lower esophagus left wall lacks the supportive organs like heart, large intestine, and body of vertebra.
Earliest symptoms are; severe pain at upper abdominal and chest pain, breathing difficulty, shock, aerodermectasia, cyanosis (chest pain :53%, Abdominal pain:51%). Distorted noise (Hamman’s sign) corresponded to heart beat heard by auscultation is recognized at 20%.
From these symptoms, it is sometimes miss-diagnosed as acute cardiac disease or upper digestive tract disorder, so that it is important to first treat with a skepticism. Aerodermectasia, mediastinal emphysema, pleural effusion, aero thorax is seen as symptom. Esophagography is an extremely effective assured diagnosis method, and leakage of contrast agent is recognized in approximately 90% of them. Position of perforation part, size, perforation direction, and with or without intrathoracic perforation can be determined. And it can get much information about treatment plan, like whether conservative medical management is possible, or thoracolaparotomy approach method for surgery.
The selection of treatment method is depending upon the size of perforation part and time passed to diagnosis, but there are conservative medical management, surgical treatment and endoscopic treatment.
Contamination by vomitus is bad at mediastinum and chest cavity, and contents flew out from both side of vertebra body via mediastinum, then become an abscess at outside of parietal pleura. Therefore, contents must be aspirated and discharged in specifying definite position, with using CT or Echo in drainage method. Washable tube is fixed at the back of mediastinum.
