Esophageal perforation as a complication of esophagogastroduodenoscopy

Abstract

Fifty years ago, esophageal perforation was common after rigid upper endoscopy.The arrival of flexible endoscopic instruments and refinement in technique have decreased its incidence; however, esophageal perforation remains an important cause of morbidity and mortality. This complication merits a high index of clinical suspicion to prevent sequelae of mediastinitis and fulminant sepsis. Although the risk of perforation with esophagogastroduodenoscopy alone is only 0.03%, this risk can increase to 17% with therapeutic interventions in the setting of underlying esophageal and systemic diseases. A wide spectrum of management options exist, ranging from conservative treatment to surgical intervention. Prompt recognition and management, within 24 hours of perforation, is critical for favorable outcomes. KEYWORDS: esophagogastroduodenoscopy, esophageal perforation, mediastinitis, sepsis, endoscopy. E sophagogastroduodenoscopy (EGD) carries a small but serious risk of esophageal perforation. Journal of Hospital Medicine1-3 With its potential for sepsis and fatal mediastinitis, prompt recognition and treatment are essential for favorable outcomes. The risk of perforation with diagnostic flexible EGD is 0.03%, which is an improvement from the 0.1%-0.4% risk associated with rigid endoscopy. 4 However, the risk of perforation can dramatically increase to 17% depending on the methods of therapeutic intervention and underlying risk factors (Table 1). 1,[5][6][7] It is estimated that 33%-75% of all esophageal perforations are iatrogenic. 8 Of those caused by EGD, therapeutic interventions portend an increased risk compared with the risk of diagnostic endoscopy alone (Table 2). 4 With the expanding role of flexible EGD and the increasing number of procedures performed, this modest risk per procedure still translates into a sizable number of perforations with their ensuing complications. 4,7 Mortality rates following esophageal perforation may approach 25%. 9 ANATOMY AND PATHOPHYSIOLOGYThe most common site of perforation is at the level of the cricopharyngeus, as it is a narrow introitus leading to the esophagus. The risk of perforation at this location is further increased with the presence of a Zenker's diverticulum or cervical osteophytes. The second most common site is proximal to the lower esophageal sphincter because of the angulation of the hiatus and the high frequency of esophageal webs, rings, reflux strictures, and hiatal

Unexpected complication of oesophagoscopy: iatrogenic aortic injury in a child

“…However, direct aortic injury during oesophagoscopy is not reported as frequently as other complications. The majority of reports mention oesophageal rupture due to foreign body removal with oesophagoscopy 1,2…”

“…Oesophagoscopy is an effective diagnostic and treatment method for oesophageal pathologies, with 0.03 to 17% complication rates 1,2. Perforation and bleeding are the most important complications of this procedure.…”

“…Perforation and bleeding are the most important complications of this procedure. Previous reports have claimed that therapeutic interventions with oesophagoscopy present more risks with regard to complications, than other diagnostic procedures 1,2…”

Hypopharynxperforation nach Ösophagogastroduodenoskopie

“…Zudem kann mit der flexiblen Endoskopie hier nur eine geringe Übersicht erreicht werden, da eine Insufflation des Hypopharynx technisch nicht möglich ist. Am zweithäufigsten kommt es zu Verletzungen im Bereich des unteren Ösophagussphinkters durch den hier vorliegenden Winkel zum Mageneingang [1]. Obwohl es äu-ßerst selten zu ernsthaften Komplikationen kommt, sollte jede Indikation zur Durchführung einer ÖGD sorgfältig gestellt sein.…”

“…Ösophagus sollte eine CT mit oralem jodhaltigen Kontrastmittel erfolgen, die zum Nachweis eines Emphysems als indirektes Perforationszeichen dient [9]. Schluckuntersuchungen mit Gastrografin ® erlauben häufiger die Detektion der Perforationslokalisation, sie bergen jedoch als Einzeldiagnostik ein erhöhtes Risiko für falsch-negative Ergebnisse [1]. Als klinische Zeichen eines Mediastinalemphysems können retrosternale Thoraxschmerzen, Fieber, eine Leukozytose und in ca.…”