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0361-803X/93/1604-0767© American Roentgen Ray Society

Esophageal Perforation: CT Findings

Charles S. White1

Philip A. Templeton1

Safuh Attar2

Received October 19, 1992; accepted after revi-sion December 2, 1992.

1Department of Radiology, University of Mary-land Medical Center, 22 5. Greene St., Baltimore,MD 21201. Address correspondence to C. S.White.

2Department of Surgery, University of MarylandMedical Center, Baltimore, MD 21201.

OBJECTIVE. Esophageal perforation is a life-threatening condition that can bequickly diagnosed on the basis of findings on contrast esophagograms when the typ-ical signs and symptoms of vomiting, chest pain, and subcutaneous emphysema

occur. If the clinical features are atypical, CT may be performed early in the clinicalcourse. Thus, recognition of the CT findings of esophageal perforation is important.

MATERIALS AND METHODS. We reviewed the CT scans of 12 patients with esoph-ageal perforation. The site of perforation was the cervical esophagus in three and thethoracic esophagus in nine. The causes of the perforations were neoplastic (fourpatients), idiopathic (three patients), iatrogenic (three patients), and traumatic (twopatients).

RESULTS. CT abnormalities included esophageal thickening in nine patients, per-iesophageal fluid in ii patients, extraluminal air in 11, and pleural effusion in nine.The site of the perforation was visible on the CT scan in two patients. In four patients(33%), CT findings were the first indication of esophageal perforation.

CONCLUSION. For patients who have atypical signs and symptoms, CT scans opti-mally define the extraluminal manifestations of esophageal perforation. Extraesoph-ageal air is the most useful finding. The CT findings may be the first indication of thediagnosis.

AJR 1993;160:767-770

Esophageal perforation is a frequently catastrophic event that classicallycauses vomiting, chest pain, and subcutaneous emphysema. When the typicalsigns and symptoms occur, the diagnosis is usually quickly confirmed by findingson contrast esophagograms. In many cases, however, the initial signs and symp-toms are nonspecific and may consist of hypotension, sepsis, or fever, falselysuggestive of myocardial infarction, acute aortic dissection, or intraabdominalabnormalities [1-4]. In addition, up to 10% of patients with esophageal perforationmay have false-negative findings on contrast esophagograms [5]. Even inpatients with known esophageal perforation, the extent of such extraesophagealabnormalities as mediastinal air and fluid cannot be assessed by using contrastesophagography.

Several case reports [4, 6-8] have suggested that CT may be useful for thediagnosis of esophageal perforation. We reviewed the CT scans of 12 patientswith esophageal perforation to evaluate the usefulness of CT for the diagnosisand assessment of this condition.

Materials and Methods

We reviewed the medical records and radiologic files of 38 patients with a discharge diag-nosis of esophageal perforation from 1986 to 1992. Fourteen patients had CT scanning dur-

ing the course of their evaluation. Two patients were excluded because their CT scans were

obtained after a corrective surgical procedure. The remaining 12 patients form the basis ofthis study. A report on one of these patients was published previously [9].

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768 WHITE ET AL. AJR:160, April 1993

The study population consisted of five men and seven women,16-79 years old (mean, 46 years). The diagnosis of esophageal

perforation was confirmed by findings on contrast esophagograms(10), at endoscopy (one), or at surgery (one). A review of the medi-cal records and radiologic studies indicated that the causes of theperforations were neoplastic (four), iatrogenic (three), idiopathic(three), and traumatic (two). The four neoplastic perforationsincluded three primary esophageal cancers and one lung cancer

invading the esophagus. None of the affected patients had received

prior treatment. The three iatrogenic perforations included twocases of postoperative rupture after primary esophageal repair oftraumatic esophageal perforation and a perforation after balloon

dilatation for achalasia. The site of perforation was the cervicalesophagus in three patients and the thoracic esophagus in nine.

All CT scans were obtained with General Electric 9800 (GeneralElectric Medical Systems, Milwaukee, WI), Somatom HiQ and Sie-

mens DRH (Siemens Medical Systems, Iselin, NJ), CGR (Paris,France), or Pfizer (Columbia, MD) CT systems. Ten chest CT scansconsisting of contiguous sections 8 or 10 mm thick and two neck CTscans consisting of contiguous sections 3 mm thick were obtained.

Six patients received IV contrast material. One patient was givenoral contrast material.

Two thoracic radiologists reviewed the CT scans and arrived at afinal interpretation by consensus. They evaluated the scans for evi-

dence of focal esophageal thickening and of air or fluid in the medi-astinum, pericardium, lower part of the neck, or pleural space. An

attempt was made to correlate the location of these abnormalitieswith the location of the esophageal perforation.

The medical records were reviewed to determine the clinical set-ting of the esophageal perforation. Particular note was made ofthose cases in which CT findings provided the first indication of thecorrect diagnosis.

Results

Of the 12 patients in the study, the esophageal wall wasfocally thickened in nine, normal in one, and poorly visual-ized because of surrounding fluid in two (Fig. 1). Fluid waspresent in the adjacent mediastinal or lower cervical areas in11 . Eleven patients had extraluminal air. The air was medias-tinal in six (Fig. 2), mediastinal and cervical in two, mediasti-nal and pleural in two, and penicardial in one. The site of theesophageal perforation correlated well with the location ofthe extraluminal air and fluid. In two cases, the precise siteof perforation was detected retrospectively (Fig. 3).

Pleural effusions occurred in nine of 10 patients in whomthe pleural space was imaged. The effusions were bilateralin seven patients and limited to the right pleural space in twopatients. Penicardial effusions and penicardial thickeningwere present in two patients each. Markedly enlarged medi-

Fig. 1 -CT scan through esophagus at sub-carinal level shows esophageal thickening in63-year-old man with spontaneous esophagealperforation (arrow).

Fig. 2.-Extensive pneumomediastinum in23-year-old woman with spontaneous esoph-ageal perforation. CT scan at level of carinashows large quantity of air in anterior mediasti-num (arrows).

Fig. 3.-Direct visualization of site of perfo-ration with an esophagopleural fistula in 56-year-old woman with esophageal cancer.

A, CT scan shows air track (arrow) extend-ing from esophagus into mediastinum.

B, CT scan immediately cephalic to A showstrack (arrow) extends to pleural cavity.

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AJR:160, April 1993 ESOPHAGEAL PERFORATION 769

Fig. 4.-Neoplastic esophageal perforationin 58-year-old woman with bronchogenic can-cer invading esophagus.

A, CT scan at level of perforation shows soft-tissue mass containing extraluminal air (ar-rows). Perforation was confirmed by esopha-gography. Esophagus cannot be detected as aseparate structure.

B, CT scan at level superior to A shows right-sided paratracheal mediastinal adenopathy (ar-row), which suggests malignant tumor is causeof perforation.

astinal lymph nodes indicated a malignant tumor as thecause of perforation in one patient (Fig. 4).

In four patients (33%), esophageal perforation had not beenconsidered initially, and abnormalities on the CT scan sug-gested the correct diagnosis. In three patients who had atypicalhistory and findings on physical examination, CT scans wereobtained after nondiagnostic chest radiognaphs. Mediastinal airwas present in all three, and the finding was suggestive of thecorrect diagnosis. In the fourth patient, an esophageal leak andmediastinal abscess developed after repair of a traumatic cervi-cal esophagus laceration; the leak and abscess were diag-nosed on the basis of CT findings. The site of the perforationwas localized on contrast esophagograms.

Discussion

Esophageal perforation is a life-threatening condition thatmay rapidly progress to fulminant mediastinitis and septicshock. Early recognition allows the prompt institution of appro-pniate medical and surgical intervention. Detection of the per-foration within 24 hr of the onset of signs and symptomsusually makes primary surgical closure possible, after whichthe survival rate is 80% or greater [10]. In most studies [5, 10-13], delay in treatment beyond 24 hr after onset adverselyaffected the prognosis. A minority of patients had the classicsigns and symptoms of esophageal perforation: retrosternalchest pain, vomiting, and mediastinal emphysema.

When these features are present, the diagnosis is con-firmed by findings on an oral contrast study. The clinical fea-tunes are variable, however, and patients may have signsand symptoms that mimic those of myocandial infarction,acute pancreatitis, on aortic dissection. Patients may alsohave hypotension and shock because of severe mediastini-tis. In such cases, the diagnosis of esophageal perforationmay not be considered initially.

Chest nadiognaphs may show pleural effusion, hydnopneu-mothonax, on mediastinal or cervical emphysema. In twostudies [14, 15] of esophageal perforation, however, theplain film findings were normal in 12% and 33% of patients,respectively. Contrast esophagognaphy has been the stan-dard technique for diagnosing esophageal perforation and

can be performed with water-soluble contrast material fol-lowed by barium. In most cases, the site of the perforation isreadily detected. Nevertheless, false-negative findings havebeen reported in up to 1 0% of patients [5].

The abnormalities seen on CT scans may be the firstimaging findings to suggest the diagnosis, as was true in

33% of our patients. The efficacy of CT results from its useas a survey technique in confusing on complicated clinicalsituations that may result from esophageal perforation.Extraluminal air was the most useful CT finding. It occurredin 92% of our cases, including the four cases in which CTfindings were the first indication of the diagnosis. The mostlikely sources of extraluminal air are rupture of the esopha-gus or tracheobronchial tree or penetrating trauma. Addi-tional CT findings such as esophageal thickening may allowfurther characterization of the underlying process. Mediasti-nal, cervical, pleural, or penicardial fluid is usually presentbut is a less specific finding. Pleural effusions were most fre-quently bilateral. The left-sided predominance of pleural effu-sions classically associated with esophageal perforation wasnot observed on CT scans [14].

Much attention has focused on therapeutic options inesophageal perforation, in particular, the issue of nonsurgi-cal management. The most widely used criteria for consen-vative management include (1) perforation contained withinthe mediastinum or between the mediastinum and visceralpleura, (2) drainage of the cavity back into the esophagus,(3) minimal signs and symptoms, and (4) minimal evidenceof sepsis [1 6]. In a recent study of 25 patients with esoph-ageal perforation, 12 of whom were treated medically, Shaf-fer et al. [1 7] concluded that the most relevant criterion formedical management was the degree of containment of theperforation. As shown in our study, CT is ideally suited fordefining the extent of extraluminal air and fluid. CT may alsobe useful in monitoring the clinical course of patients treatedconservatively.

Although this report contains the largest series to date ofpatients with esophageal perforation evaluated by CT, thenumbers are relatively small and are not conclusive as to theprecise clinical circumstances in which CT should be usedfor diagnosis. The influence of CT findings on treatment

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770 WHITE ET AL. AJR:160, April1993

options remains to be defined. A larger study with a prospec-tive design is needed to address these issues. Oral contrastmaterial is not routinely used for chest CT at our institutionand was administered to only one patient in the study group.Nevertheless, the CT findings of extraluminal air and fluidand esophageal thickening appear to be sufficiently diagnos-tic to eliminate the need for oral contrast material. Our datasuggest that CT is useful for suggesting the diagnosis ofesophageal perforation in situations in which the signs andsymptoms are complicated or confusing. CT is the best tech-nique for defining the paraesophageal manifestations of

esophageal rupture and may have a role in selecting patients

for medical management.

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