Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

Esophageal perforation is a well-characterized and potentially life-threatening clinical situation [1-3]. Several factors, including the difficulty of accessing the esophagus, the lack of a strong serosal layer, the unusual blood supply of the organ and the proximity of vital structures, all contribute to this condition's high morbidity and to a mortality rate of at least 20% [4-6]. In addition, the diversity of clinical symptoms and signs combined with a lack of individual experience regarding this particular condition may impede rapid identification of this potentially hazardous situation. Accordingly, delayed diagnostic work-up may hinder timely and appropriate treatment with a negative effect on patient outcome [7].The scientific evidence that guides management of esophageal perforation is based mainly on retrospective studies at single institutions as well as on a few nationwide studies [1,4-6,8-10]. Randomized studies are non-existent. Nevertheless, attention should be paid to early diagnosis and immediate treatment to save lives and to decrease morbidity and long-term sequelae.In this review, we focus on the clinical aspects of esophageal perforation that are most helpful for early suspicion and that should prompt appropriate diagnostic tasks. We also highlight factors with particular clinical importance for informed decision-making during the first 24 hours of treatment in-hospital.The low incidence of esophageal perforation is supported by reports from institutional series that are often based on consecutive patients diagnosed over a period of decades [9,11-13]. However, referral bias and publication bias may obscure accurate incidence statistics. In a recent population-based study in Iceland, the age-standard incidence was 3.1/1 000 000/year [6]. Nevertheless, the true incidence of esophageal perforation worldwide is not clear [14]. Most patients are in their sixties, and esophageal perforation is slightly more common in males [5].Esophagus rupture is usua