{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 31, Ep 4 of 4: Esophageal Perforation and Ogilvie Syndrome","html":"","width":"100%","height":180,"duration":819,"description":"Episode four closes the chapter with two emergencies that run on the same cue-plus-threshold-plus-intervention shape, where the threshold is a mechanism in disguise. For esophageal perforation the clock starts when the wall tears, and the twenty-four hour window separates clean primary closure from sealed stent and drainage because the mediastinal tissue planes change from friend to enemy. For acute colonic pseudo-obstruction the clock starts when the colon stops moving, and a four-step algorithm anchored by a cecal-diameter threshold and a neostigmine-with-cardiac-monitoring decision moves the patient from the conservative bundle to pharmacology to decompression to surgery. Laplace's law explains why the cecum fails first and the neostigmine contraindication list explains why every dose comes with atropine at the bedside.\n \nTopics covered\n\nCauses of esophageal perforation and Boerhaave\nThe Mackler triad and recognition stem\nPerforation site and left-sided effusion\nWater-soluble contrast imaging and antibiotics\nThe twenty-four hour repair-versus-stent window\nOgilvie syndrome and autonomic imbalance\nRuling out mechanical obstruction\nNeostigmine and cardiac monitoring\nColonoscopic decompression and surgery\n \nKey decisions\n\nImage suspected esophageal perforation with CT chest and oral water-soluble contrast looking for pneumomediastinum, avoiding barium initially because barium granulomatous mediastinitis is a feared complication, since a normal chest radiograph does not exclude the diagnosis.\nCover both mediastinal compartments with piperacillin-tazobactam or a meropenem-based regimen plus antifungal coverage in severe disease, and place nasogastric decompression under fluoroscopic guidance to avoid the leak.\nRepair Boerhaave and large iatrogenic perforations primarily within twenty-four hours while tissue planes hold, shift beyond twenty-four hours to covered self-expanding metal stents with drainage, and clip small iatrogenic perforations caught at the index...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}