• Anthony DeVivo, Alexander Y Sheng, Alex Koyfman, and Brit Long.
• Department of Emergency Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at The Mount Sinai Hospital, New York City, NY, USA.
• Am J Emerg Med. 2022 Mar 1; 53: 29-36.

IntroductionEsophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality.ObjectiveThis article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence.DiscussionEsophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting.ConclusionsAn understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.Published by Elsevier Inc.

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