Rupture Oesophagus (a)

This 92 year old Indian lady. She had dysphagia to solids, then to fluids for one month. She had history of twice oesophageal dilatation  in India during the last 6 months.

Gastrographin study showed smooth narrowing at the lower 1/3 of the oesophagus but the mucosa was intact. The stricture was due to neuromuscular incoordination. The risk of rigid oesophagoscopy and dilatation was discussed with the family because of patient's age and poor general condition. The family accepted the  procedure.
X-ray with gastrographin: Image1, Image2

Rigid oesophagoscopy started and oesophagoscope passed easily through the stricture and cardio-oesophageal junction to the stomach.

Immediately when she recovered from anesthesia she put her hand on the epigastrium and felt severe pain radiating to the back.

Immediate chest x-ray was normal. Patient was kept under close observation.

X-ray chest was repeated after 6 hours which showed left sided hydro- pneumothorax.
A-P view

An IC drainage tube was inserted and connected to under water seal system.

Gastrographin study showed tear in the dilated area. patient was kept under observation and conservative treatment was given but she expired later.
Image1, Image2

Evidence of Rupture oesophagus :
        1- Pneumo mediastinum. The air may reach to supraclavicular region causing surgical emphysema
        2- Pneumothorax, this happens if mediastinal pleura ruptures, so that the air collects in the pleural cavity.
        3- Pleural effusion. Since we have more than 1 and 1/2 liters saliva daily.
        4- Air under diaphragm. Since 4 cm of the oesophagus is in the abdominal cavity.