Esophageal perforation is a rare but serious medical emergency with a very high mortality rate, especially if the diagnosis is delayed.
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Epidemiology
Most patients are in their sixties with a slight male predominance 5.
Clinical presentation
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.
Pathology
The lack of a serosal layer may make the esophagus more susceptible to injury than other parts of the gastrointestinal tract 3.
Etiology
-
iatrogenic
post-instrumentation or post-thoracic surgery (most common: ~80% of cases) 3,4
complication of acute radiation-induced esophagitis
-
trauma: both blunt (crush-type injury) and penetrating
occurs in <0.1% of blunt chest trauma 2
foreign body ingestion
corrosive material ingestion
spontaneous rupture post-vomiting (Boerhaave syndrome)
Radiographic features
Plain radiograph
Possible clues on chest radiographs include:
pneumomediastinum, abnormal cardiomediastinal contour, pneumothorax and pleural effusion are all features, although non-specific, for esophageal perforation 5
widening of the mediastinal shadow: non-specific on its own
Fluoroscopy
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
CT
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 esophagus: highly suggestive 2,4
pleural or mediastinal fluid
pericardial or pleural effusions can be seen
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.
Treatment and prognosis
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.
Complications
acute mediastinitis 2,3
pneumonia 2,3
empyema 2,3
sepsis 2,3
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