Suspected Esophageal Perforation
Adult with chest, neck or epigastric pain after vomiting, endoscopy, dilatation, trauma or a swallowed foreign body
All Pathways
Cardiothoracic SurgeryEmergency
Esophageal Perforation / Boerhaave Syndrome (WSES 2019)
Esophageal Perforation / Boerhaave Syndrome (WSES 2019): Suspected Esophageal Perforation → Time-critical. Not for children or caustic injury → Clinical...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning Time-critical. Not for children or caustic injury
Treat within 24 h if possible: mortality is under 10% within 24 h and about 30% after.
- Children: get paediatric surgical advice; this pathway is for adults
- Caustic ingestion: use the caustic ingestion pathway; transmural necrosis needs emergency resection
- Trauma: treat life-threatening associated injuries first
03Action Clinical Recognition
Presentation is often non-specific; more than half are diagnosed late. Keep a high index of suspicion.
- Mackler triad: vomiting, chest pain, subcutaneous emphysema
- Also: fever, dysphagia, odynophagia, dyspnoea, tachycardia, sepsis
- Hamman sign (mediastinal crunch); pleural effusion, often left-sided
- Causes: iatrogenic (about 60%; endoscopy, dilatation), Boerhaave after vomiting (about 15%; usually left lower third, 3-8 cm tear), trauma, foreign body, cancer
04Action Immediate Management
Start as soon as perforation is suspected. Do not wait for the score.
- Resuscitate; treat sepsis; take blood cultures
- Nil by mouth. Do not pass a nasogastric tube blindly
- IV broad-spectrum antibiotics (aerobic and anaerobic cover); PPI
- Urgent upper GI or thoracic surgical referral; transfer to a specialist centre
- Perforation seen during endoscopy: switch to CO2; close it at once if feasible; decompress tension pneumothorax or pneumoperitoneum at once
05Action Diagnostic Workup
CT with oral water-soluble contrast is the first-choice test.
- CT chest and abdomen with IV contrast and oral water-soluble contrast (CT oesophagogram); sensitivity 92-100%
- Aspiration risk or tracheo-oesophageal fistula: do not use Gastrografin (pulmonary oedema, pneumonitis); use a low-osmolar contrast agent
- Chest X-ray: pneumomediastinum, effusion, pneumothorax, surgical emphysema
- Bloods: FBC, electrolytes, urea, creatinine, LFTs, blood gas, lactate
- Fluoroscopic swallow (selected cases): water-soluble contrast first; barium only if that is negative and there is no aspiration risk
- CT equivocal: endoscopy by an expert, CO2 and low-flow insufflation
06Decision Perforation confirmed?
- If Yes
07Action Confirmed: Pittsburgh Severity Score
Supports the decision. It does not replace it.
- 1 point each: age over 75 y, HR over 100/min, WCC over 10 x10^9/L, pleural effusion
- 2 points each: fever over 38.5 °C, non-contained leak on CT, respiratory compromise (RR over 30/min, rising O2 need or ventilation), diagnosis over 24 h after onset
- 3 points each: cancer, hypotension (SBP under 90 mmHg)
- Low 2 or less; intermediate 3-5; high over 5 (maximum 18)
- Low score may suit non-operative care. Sepsis, shock or a non-contained leak need intervention whatever the score
08Decision Any non-operative criterion missing?
Non-operative care needs all of: stable, no sepsis, early (under 24 h), cervical or thoracic site, contained leak draining back into the oesophagus, no massive pleural contamination, no cancer or other oesophageal disease, expert team available 24 h.
- If Yes
09Decision Emergency surgery needed?
A non-operative criterion is missing. Yes if any: shock or ongoing sepsis; large contamination that cannot be drained percutaneously; perforation not caused by endoscopy; defect not suited to endoscopic therapy; no expert endoscopist. No: endoscopic treatment first.
- If Yes
10Action Surgery needed or deteriorates: Emergency Surgery
Operate as soon as possible. Delay increases mortality. Unresectable or palliative cancer: covered stent, not resection.
- Principles: debride to viable tissue, close the defect, buttress with vascularised tissue, drain widely
- Primary repair when the edges are viable, even after 24 h; delay lowers the chance that the repair holds
- Repair not feasible (over 50% of circumference, unstable, extensive damage): drainage, T-tube, exclusion or diversion
- Resectable cancer or end-stage oesophageal disease in a fit patient: consider resection in a specialist centre
- Feeding jejunostomy; gastric decompression
- Late presentation or very high surgical risk: expert centres may consider endoscopic therapy with drainage
11Action Surgical Approach by Site
Tailor to the site of perforation.
- Cervical: left neck incision; repair if feasible, buttress, drain. Not feasible: drainage with or without oesophagostomy
- Thoracic: thoracotomy, side guided by CT (lower third usually left); repair, buttress (intercostal muscle or pleura), drain
- Abdominal: laparotomy; repair with fundoplication buttress; drain the subphrenic space
- Minimally invasive repair: expert centres only
- Diversion or resection: cervical oesophagostomy and feeding jejunostomy
12Action ICU Care and Monitoring
Ongoing management after any treatment.
- Sepsis care; drain new collections
- Nutrition: enteral by jejunostomy or nasojejunal tube; parenteral if enteral not possible
- Confirm healing with a contrast study before oral intake
- Watch for persistent leak, empyema, abscess, fistula
- Persistent leak after surgery: consider endoscopic stent
13Outcome Healed
Follow up for stricture. Reconstruction 6-12 months after diversion or resection.
If No14Action Endoscopy-related: Endoscopic Treatment First
First-step endoscopic therapy by an expert team, with the surgical team involved. Not if shock, ongoing sepsis or deterioration: emergency surgery.
- Close or cover: TTS clips under 10 mm; OTS clips over 10 mm; covered stent over 20 mm (remove at about 4-6 weeks); vacuum therapy in expert centres
- Malignant stricture or unresectable cancer: covered stent
- Drain mediastinal or pleural collections: percutaneous, chest drain or VATS
- Nil by mouth; IV broad-spectrum antibiotics; PPI; early enteral or parenteral nutrition
- Failed closure or deterioration: emergency surgery
15Decision Deteriorates or leak not controlled?
Reassess often, clinically and with imaging. Yes: emergency surgery. No: ICU care and monitoring.
- If Yes
- Path rejoins step 10Shared downstream outcome
If No- Path rejoins step 12Shared downstream outcome
If No16Action All criteria met: Non-Operative Management
Only if stable with a contained leak. Not if sepsis, shock, cancer or pre-existing oesophageal disease.
- Nil by mouth; nasogastric tube only under endoscopic guidance
- IV broad-spectrum antibiotics (aerobic and anaerobic); antifungal per local advice
- PPI
- Early nutrition: enteral (nasojejunal or jejunostomy) or parenteral
- Drain collections: percutaneous or VATS
- Close surveillance by the oesophageal team
17Action Non-operative: Endoscopic Closure or Cover
Adjunct to non-operative care. Choose by defect size and local expertise.
- TTS clips: defects under 10 mm; OTS clips: over 10 mm
- Covered self-expanding stent: defects over 20 mm or malignant perforation; plan removal at about 4-6 weeks
- Endoscopic vacuum therapy: option in expert centres
- Drain collections as well; use CO2 insufflation
- Path rejoins step 15Shared downstream outcome
If No18End Not confirmed: consider other causes
Aortic dissection, oesophageal intramural haematoma, acute coronary syndrome, pneumothorax. If suspicion remains: expert endoscopy or repeat CT.
Guideline Source
Esophageal emergencies: WSES guidelines (Chirica et al., World J Emerg Surg 2019)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Not for children or caustic ingestion. In trauma, treat associated injuries first.
- Manage in a specialist centre with 24-hour oesophageal surgery, endoscopy, interventional radiology and ICU.
- Evidence is mostly low quality (case series and expert opinion); the Pittsburgh score supports but does not replace judgement.
- The STS 2026 expert consensus (Ann Thorac Surg 2026) favours CT oesophagogram and individualised, often endoscopic, care; only its abstract was reviewed.
Contraindicated Populations
ChildrenCaustic ingestionEsophageal foreign body without perforation
Applicable Regions
USAUUKEU
AU: Refer or transfer early to a tertiary centre with 24-hour upper GI or thoracic surgery, endoscopy, interventional radiology and ICU.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Esophageal Perforation / Boerhaave Syndrome (WSES 2019)?
The Esophageal Perforation / Boerhaave Syndrome (WSES 2019) is a emergency clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on Esophageal emergencies: WSES guidelines (Chirica et al., World J Emerg Surg 2019).
What guideline is the Esophageal Perforation / Boerhaave Syndrome (WSES 2019) based on?
This algorithm is based on Esophageal emergencies: WSES guidelines (Chirica et al., World J Emerg Surg 2019) (DOI: 10.1186/s13017-019-0245-2).
What are the limitations of the Esophageal Perforation / Boerhaave Syndrome (WSES 2019)?
Known limitations include: Adults only. Not for children or caustic ingestion. In trauma, treat associated injuries first.; Manage in a specialist centre with 24-hour oesophageal surgery, endoscopy, interventional radiology and ICU.; Evidence is mostly low quality (case series and expert opinion); the Pittsburgh score supports but does not replace judgement.; The STS 2026 expert consensus (Ann Thorac Surg 2026) favours CT oesophagogram and individualised, often endoscopic, care; only its abstract was reviewed.. Individual patient factors may require deviation from these recommendations.
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