Spontaneous rupture of the esophagus.

Perforation of the esophagus for any reason on at any level is always a grave lesion and one which, if untreated, is not compatible to life. The clinical symptoms of spontaneous rupture of the esophagus are not generally recognized. The majority of the cases thus far recorded in the literature, now more than 66, were not diagnosed before death and in many instances were not even suspected before the postmortem examination. Since the first classical description of the condition by Boenhave1 published in 1724, there have appeared in the literature isolated cases of this condition. Eliason and Welty2 reported three fatal cases of spontaneous rupture of the esophagus and reviewed the theories as to their etiology, plus the usual clinical and autopsy findings. Apparently the predominating cause is the sudden increase in intra-esophageal pressure brought on by forceful vomiting, straining or external trauma to the abdomen or thorax. In practically all cases coming to autopsy a linear tear is found in the esophagus just proximal to the cardia. Associated with this are variable degrees of mediastinitis and pleunitis. Whether or not preexisting pathologic changes must be present in the esophagus wall before rupture can occur has not been decided definitely. More recent reports include that of Scholefield3 who described two cases that were diagnosed correctly. One patient died before surgery could be performed; the other was operated upon and recovery was prompt. This was the third successful surgical repair recorded in the literature. Cliffton4 recently reported three cases, one of which was treated successfully by surgery; the second, a fatal case of rupture, was diagnosed incorrectly; the third case was diagnosed as a spontaneous perforation of the esophagus and was treated by laparotomy, with survival after late diagnosis and thoracotomy drainage. It is generally accepted that thoracotomy with primary repair of the rupture is the procedure of choice, especially in tears in the intrathoracic portion of the esophagus. However, Temple5 advocates expectant therapy in cervical perforations, especially where the tear is small and easily accessible.