Esophageal perforation

Last revised by Ammar Ashraf on 8 Jul 2023

Esophageal 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 sixties with a slight male predominance 5

Esophageal rupture is iatrogenic from instrumentation and surgery in ~80% of cases. If undetected during a procedure, or caused by something else, chest pain is present in 70% of cases 3,4. Other symptoms are more variable but include neck or epigastric pain, dysphagia and dyspnea 5,6. Subcutaneous emphysema 4, and symptoms from secondary bleeding and infection, may be part of the presentation 1

The lack of a serosal layer may make the esophagus more susceptible to injury than other parts of the gastrointestinal tract 3

Possible clues on chest radiographs include:

  • most sensitive within the first 24 hours 1

  • patient examined semi-supine (~20 degrees) on the fluoroscopy table

  • a low-osmolar water-soluble agent should be used initially as barium can cause mediastinitis 1

  • esophageal perforation may be represented as mucosal irregularity or extraluminal oral contrast leak

  • 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:

Water-soluble oral contrast can be administered 20 minutes before scanning to demonstrate extraluminal contrast leak. Intravenous contrast is usually administered to delineate the esophageal wall (25-60-second delay) 8.

There is a high mortality rate, estimated between 25 to 50% in some series 1,4, which 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 stent placement vs. medical management 5,6,9

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