This protocol applies to patients with spontaneous (Boerhaave) esophageal perforation who present within 24 hours of onset, are hemodynamically stable, have a contained perforation with minimal peri-esophageal contamination, and show no symptoms or signs of sepsis.
Spontaneous esophageal perforation typically follows an abrupt rise in esophageal pressure during vomiting. When the disruption is contained, contamination is minimal, and the patient remains stable without sepsis at an early stage, a non-operative approach can be considered — provided highly specialised monitoring is available.
The protocol for this scenario is built around non-operative management incorporating antibiotic therapy and targeted supportive measures — the complete sequencing, decision criteria, and full regimen are available in the structured protocol below.
Spontaneous esophageal perforation (Boerhaave syndrome) is most often due to an abrupt increase in the esophageal pressure following a vomiting effort in the absence of relaxation of the superior esophageal sphincter.
Non-operative management (NOM) of EP can be considered in stable patients with early presentation, contained esophageal disruption, and minimal contamination of surrounding spaces if highly specialized surveillance is available (Grade 1C).
Patients eligible for NOM should be kept on nil per os, administered broad spectrum antibiotics (aerobic and anaerobic bacteria), and proton pump inhibitor therapy (Grade 1C).
Early introduction of nutritional support by enteral feeding or total parenteral nutrition is essential for esophageal healing (Grade 1C).
Endoscopic placement of a nasogastric tube is recommended (Grade 2A).
DOI: 10.1186/s13017-019-0245-2
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