Oesophageal perforation is a rare but serious medical emergency with a very high mortality rate, especially if the diagnosis is delayed.
Most patients are in their 60s with a slight male predominance 5.
If a perforation is not detected during the procedure or operation, the patient may present with neck, chest or epigastric pain, dysphagia or dyspnoea 3-4 although symptoms asides from chest pain (present in 70%) are quite variable 5-6. Subcutaneous emphysema may also be present 4.
The lack of a serosal layer may make the oesophagus more susceptible to injury than other parts of the gastrointestinal tract 3.
- iatrogenic, e.g. post instrumentation or post thoracic surgery (most common ~80% of cases) 3-4
- trauma: both blunt (crush-type injury) and penetrating
- occurs in <0.1% of blunt chest trauma 2
- foreign body ingestion
- corrosive material ingestion
- oesophageal cancer
- spontaneous rupture post vomiting (Boerhaave syndrome)
Possible cues on chest radiographs include:
- pneumomediastinum, abnormal cardiomediastinal contour, pneumothorax and pleural effusion are all features, although non-specific, for oesophageal perforation 5
- widening of the mediastinal shadow: non-specific on its own
- most sensitive within the first 24 hours 1
- patient examined semi-supine (~20 degrees) on fluoroscopy table
- a water-soluble agent should be used initially as barium can cause mediastinitis
- oesophageal perforation may be represented as mucosal irregularity or gross extraluminal contrast extravasation
- some authors suggest the use of small amounts of low or high concentrations of barium if no leak is evident on initial screening with water soluble contrast 8
The role of CT is usually to look for stigmata of perforation when fluoroscopy is equivocal, and there is persisting suspicion of perforation. These include:
- extraluminal gas locules in the mediastinum or abdominal cavity, adjacent to the oesophagus are highly suggestive 2, 4
- pleural or mediastinal fluid
- pneumomediastinum or pneumothorax
- pericardial or pleural effusions can be seen
Water soluble oral contrast can be administered 20 minutes before scanning to demonstrate extravasation. Intravenous contrast is usually administered to delineate the oesophageal wall (25 - 60 second delay) 8.
Treatment and prognosis
There is a high mortality rate, estimated between 25 to 50% in some series 1, 4 and this is significantly increased if the diagnosis is delayed beyond 24 hours 6.
The rarity of this condition means that treatment is not well established and options include surgical or endoscopic management vs. medical management 5-6.
Complications 1, 3
- oesophageal dysmotility
- oesophageal tumours
- benign oesophageal neoplasms
- malignant oesophageal neoplasms
- gastro-oesophageal reflux disease
- oesophageal stricture
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- 2. Emergency Radiology. Springer. (2007) ISBN:3540689087. Read it at Google Books - Find it at Amazon
- 3. Chung DYF, Mondal D, Holmes EJ et-al. Emergency cross-sectional radiology. Cambridge University Press. ISBN:0521279534. Read it at Google Books - Find it at Amazon
- 4. Gore RM, Levine MS. High Yield Imaging: Gastrointestinal: Expert Consult - Online and Print, 1e (HIGH YIELD in Radiology). Saunders. ISBN:1416055444. Read it at Google Books - Find it at Amazon
- 5. Søreide JA, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg Med. 2011;19 (1): 66. doi:10.1186/1757-7241-19-66 - Free text at pubmed - Pubmed citation
- 6. Hasimoto CN, Cataneo C, Eldib R et-al. Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies. Acta Cir Bras. 2013;28 (4): 266-71. doi:10.1590/S0102-86502013000400006 - Pubmed citation
- 7. Giménez A, Franquet T, Erasmus JJ et-al. Thoracic complications of esophageal disorders. Radiographics. 2002;22 Spec No (suppl 1): S247-58. Radiographics (full text) - doi:10.1148/radiographics.22.suppl_1.g02oc18s247 - Pubmed citation
- 8. Emergencies in Radiology. Oxford University Press. ISBN:019923843X. Read it at Google Books - Find it at Amazon