Guideline sources The following summarized guidelines for the evaluation and management of esophageal perforation are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2019). 1 Guidelines 1. Diagnostic investigations Laboratory studies: Obtain routine blood tests in patients with suspected esophageal perforation: CBC liver tests (bilirubin, ALT, AST) urea creatinine electrolytes (sodium, potassium, chlorine, magnesium, calcium) pH serum lactate. B Computed tomography: obtain contrast-enhanced CT and CT esophagography as the imaging modality of choice in patients with suspected esophageal perforation. B https://web.pathway.md/diseases/recxZg9dX8xSZrM1l 1/3 6/29/23, 4:19 AM Esophageal perforation Pathway 2. Diagnostic procedures Upper gastrointestinal endoscopy: perform diagnostic endoscopy in patients with suspected esophageal perforation and doubtful CT findings. B 3. Medical management Antibiotics: administer broad-spectrum antibiotics (aerobic and anaerobic bacteria) in patients eligible for non-surgical management. B Proton pump inhibitors: administer PPIs in patients eligible for non-surgical management. B 4. Nonpharmacologic interventions Indications for non-surgical management: consider non-surgical management of esophageal perforation in stable patients with early presentation, contained esophageal disruption, and minimal contamination of surrounding spaces if highly specialized surveillance is available. B Nutritional support: keep patients eligible for non-surgical management NPO. B Show 2 more 5. Therapeutic procedures Therapeutic endoscopy: Perform endoscopic treatment for closing esophageal perforation that occur and are recognized during an endoscopic procedure. B Consider endoscopy as first-line therapy in patients with late presentation and in patients with non-endoscopic esophageal perforation. C 6. Surgical interventions Surgery: Proceed with surgery in all patients who do not meet the criteria for non-surgical management: delay in management of < 24 h absence of symptoms and signs of sepsis cervical or thoracic location of the esophageal perforation contained perforation by surrounding tissues (intramural; minimal peri-esophageal extravasation of contrast material with intra-esophageal drainage; absence of massive pleural contamination) no preexistent esophageal disease possibility of close surveillance by expert esophageal team availability of surgical and radiological skills all day and all night. B Show 7 more https://web.pathway.md/diseases/recxZg9dX8xSZrM1l 2/3 6/29/23, 4:19 AM Esophageal perforation Pathway References 1. Mircea Chirica, Michael D Kelly, Stefano Siboni et al. Esophageal emergencies: WSES guidelines. World J Emerg Surg. 2019 May 31;14 26. Open 2. Jeffrey H Lee, Prashant Kedia, Stavros N Stavropoulos et al. AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol Hepatol. 2021 Nov;19 11 2252 2261.e2. Open https://web.pathway.md/diseases/recxZg9dX8xSZrM1l 3/3