767

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Esophageal

Perforation:

CT Findings

Charles S. White1 Philip A. Templeton1 Safuh Attar2

OBJECTIVE. Esophageal perforation is a life-threatening condition quickly diagnosed on the basis of findings on contrast esophagograms
ical signs and symptoms of vomiting, chest pain, and subcutaneous

that can be when the typemphysema

occur.
course.

If the clinical
Thus,

features

are atypical,

CT may be performed
of esophageal

early in the clinical

is important.

recognition

of the CT findings

perforation

MATERIALS AND METHODS. We reviewed the CT scans of 12 patients with esophageal perforation. The site of perforation was the cervical esophagus in three and the
thoracic esophagus in nine. The causes of the perforations were neoplastic (four patients), idiopathic (three patients), iatrogenic (three patients), and traumatic (two patients). RESULTS. CT abnormalities included esophageal thickening in nine patients, periesophageal 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 ageal air is the most useful diagnosis.

manifestations of esophageal perforation. Extraesophfinding. The CT findings may be the first indication of the

AJR 1993;160:767-770 Esophageal perforation is a frequently catastrophic event that classically causes vomiting, chest pain, and subcutaneous emphysema. When the typical signs and symptoms occur, the diagnosis is usually quickly confirmed by findings on contrast esophagograms. In many cases, however, the initial signs and symptoms are nonspecific and may consist of hypotension, sepsis, or fever, falsely suggestive of myocardial infarction, acute aortic dissection, or intraabdominal abnormalities [1-4]. In addition, up to 10% of patients with esophageal perforation may have false-negative findings on contrast esophagograms [5]. Even in patients with known esophageal perforation, the extent of such extraesophageal abnormalities as mediastinal air and fluid cannot be assessed by using contrast esophagography. Several case reports [4, 6-8] have suggested that CT may be useful for the diagnosis of esophageal perforation. We reviewed the CT scans of 12 patients with esophageal perforation to evaluate the usefulness of CT for the diagnosis and assessment of this condition.

Received October 19, 1992; accepted sion December 2, 1992.

after revi-

1Department of Radiology, University of Maryland Medical Center, 22 5. Greene St., Baltimore, MD 21201. Address correspondence to C. S. White. 2Department Medical Center, American of Surgery, University of Maryland Baltimore, MD 21201. Ray Society

Materials
nosis ing the

and Methods the medical

perforation evaluation. of their

We reviewed
of esophageal course

records and radiologic

from Two 1986 to 1992. were was patients

files of 38 patients with a discharge

Fourteen excluded patients because previously had their [9]. CT scanning CT scans

diagdurwere

0361-803X/93/1604-0767
Roentgen

obtained
this study.

after

a corrective
on one

surgical
of these

procedure.
patients

The remaining
published

12 patients

form

the basis

of

A report

768

WHITE

ET AL.

AJR:160,

April 1993

The
16-79

study
years

population
old (mean,

consisted
46 years).

of five men
The

and seven

women,

attempt
with the

was made to correlate

location of the esophageal

the location
perforation.

of these abnormalities

diagnosis

of esophageal

perforation

was confirmed

by findings

on contrast

esophagograms

(10), at endoscopy (one), or at surgery (one). A review of the medical records and radiologic studies indicated that the causes of the

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perforations were neoplastic (four), (three), and traumatic (two). The

included invading prior three the treatment. primary esophagus. The esophageal None three of the iatrogenic

iatrogenic (three), idiopathic four neoplastic perforations

cancers affected and one lung had included cancer received patients

The medical records were reviewed to determine the clinical setting of the esophageal perforation. Particular note was made of those cases in which CT findings provided the first indication of the correct diagnosis.

Results
of

perforations

two
balloon

cases
traumatic dilatation

of postoperative
esophageal for achalasia.

rupture
perforation The

after
and site

primary

esophageal
after

repair

a perforation

of perforation

was the cervical

in nine.
HiQ and Sie-

esophagus
Electric mens

in three
Medical

patients

and the thoracic

esophagus
Somatom Iselin, NJ),

All CT scans were obtained

Systems, DRH (Siemens of contiguous Medical sections

with General
WI), Systems,

Electric 9800 (General CGR (Paris,

Milwaukee,

France),

consisting

Ten chest CT scans thick and two neck CT scans consisting of contiguous sections 3 mm thick were obtained. Six patients received IV contrast material. One patient was given
8 or 10 mm

or Pfizer

(Columbia,

MD) CT systems.

oral contrast material. Two thoracic radiologists

final interpretation

reviewed
They

the CT scans and arrived at a

evaluated the scans for evi-

by consensus.

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

Of the 12 patients in the study, the esophageal wall was focally thickened in nine, normal in one, and poorly visualized because of surrounding fluid in two (Fig. 1). Fluid was present in the adjacent mediastinal or lower cervical areas in 11 . Eleven patients had extraluminal air. The air was mediastinal in six (Fig. 2), mediastinal and cervical in two, mediastinal and pleural in two, and penicardial in one. The site of the esophageal perforation correlated well with the location of the extraluminal air and fluid. In two cases, the precise site of perforation was detected retrospectively (Fig. 3). Pleural effusions occurred in nine of 10 patients in whom the pleural space was imaged. The effusions were bilateral in seven patients and limited to the right pleural space in two patients. Penicardial effusions and penicardial thickening were present in two patients each. Markedly enlarged medi-

Fig. 1 -CT scan through esophagus at subcarinal level shows esophageal thickening in
63-year-old

perforation

man with (arrow).

spontaneous

esophageal

Fig. 2.-Extensive 23-year-old woman

pneumomediastinum with spontaneous

in esoph-

ageal perforation. CT scan at level of carina shows large quantity of air in anterior mediastinum (arrows).

Fig. 3.-Direct
ration with

visualization

of site of perfofistula in 56-

an esophagopleural

year-old woman with esophageal cancer. A, CT scan shows air track (arrow) extending from esophagus into mediastinum. B, CT scan immediately cephalic to A shows track (arrow) extends to pleural cavity.

AJR:160,

April

1993

ESOPHAGEAL

PERFORATION

769

Fig. 4.-Neoplastic
in 58-year-old cer invading

esophageal

perforation
can-

woman with esophagus.

bronchogenic

A, CT scan at level of perforation

shows soft-

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tissue mass containing extraluminal air (arrows). Perforation was confirmed by esophagography. Esophagus cannot be detected as a separate structure. B, CT scan at level superior to A shows rightsided paratracheal mediastinal adenopathy (arrow), which suggests malignant tumor is cause of perforation.

astinal lymph nodes indicated a malignant tumor as the cause of perforation in one patient (Fig. 4). In four patients (33%), esophageal perforation had not been considered initially, and abnormalities on the CT scan suggested the correct diagnosis. In three patients who had atypical history and findings on physical examination, CT scans were obtained after nondiagnostic chest radiognaphs. Mediastinal air was present in all three, and the finding was suggestive of the correct diagnosis. In the fourth patient, an esophageal leak and mediastinal abscess developed after repair of a traumatic cervical esophagus laceration; the leak and abscess were diagnosed on the basis of CT findings. The site of the perforation was localized on contrast esophagograms.

can

Discussion Esophageal perforation is a life-threatening condition that may rapidly progress to fulminant mediastinitis and septic shock. Early recognition allows the prompt institution of appropniate medical and surgical intervention. Detection of the perforation within 24 hr of the onset of signs and symptoms usually makes primary surgical closure possible, after which the survival rate is 80% or greater [10]. In most studies [5, 1013], delay in treatment beyond 24 hr after onset adversely affected the prognosis. A minority of patients had the classic signs and symptoms of esophageal perforation: retrosternal chest pain, vomiting, and mediastinal emphysema. When these features are present, the diagnosis is confirmed by findings on an oral contrast study. The clinical featunes are variable, however, and patients may have signs and symptoms that mimic those of myocandial infarction, acute pancreatitis, on aortic dissection. Patients may also have hypotension and shock because of severe mediastinitis. In such cases, the diagnosis of esophageal perforation may not be considered initially. Chest nadiognaphs may show pleural effusion, hydnopneumothonax, on mediastinal or cervical emphysema. In two studies [14, 15] of esophageal perforation, however, the plain film findings were normal in 12% and 33% of patients, respectively. Contrast esophagognaphy has been the standard technique for diagnosing esophageal perforation and

contrast material folsite of the perforation is readily detected. Nevertheless, false-negative findings have been reported in up to 1 0% of patients [5]. The abnormalities seen on CT scans may be the first imaging findings to suggest the diagnosis, as was true in 33% of our patients. The efficacy of CT results from its use as a survey technique in confusing on complicated clinical situations that may result from esophageal perforation. Extraluminal air was the most useful CT finding. It occurred in 92% of our cases, including the four cases in which CT findings were the first indication of the diagnosis. The most likely sources of extraluminal air are rupture of the esophagus or tracheobronchial tree or penetrating trauma. Additional CT findings such as esophageal thickening may allow further characterization of the underlying process. Mediastinal, cervical, pleural, or penicardial fluid is usually present but is a less specific finding. Pleural effusions were most frequently bilateral. The left-sided predominance of pleural effusions classically associated with esophageal perforation was not observed on CT scans [14]. Much attention has focused on therapeutic options in esophageal perforation, in particular, the issue of nonsurgical management. The most widely used criteria for consenvative management include (1) perforation contained within the mediastinum or between the mediastinum and visceral pleura, (2) drainage of the cavity back into the esophagus, (3) minimal signs and symptoms, and (4) minimal evidence of sepsis [1 6]. In a recent study of 25 patients with esophageal perforation, 12 of whom were treated medically, Shaffer et al. [1 7] concluded that the most relevant criterion for medical management was the degree of containment of the perforation. As shown in our study, CT is ideally suited for defining the extent of extraluminal air and fluid. CT may also be useful in monitoring the clinical course of patients treated conservatively. Although this report contains the largest series to date of patients with esophageal perforation evaluated by CT, the numbers are relatively small and are not conclusive as to the precise clinical circumstances in which CT should be used for diagnosis. The influence of CT findings on treatment
lowed by barium. In most cases, the

be performed

with

water-soluble

770

WHITE

ET AL.

AJR:160,

April1993

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options remains to be defined. A larger study with a prospective design is needed to address these issues. Oral contrast material is not routinely used for chest CT at our institution and was administered to only one patient in the study group. Nevertheless, the CT findings of extraluminal air and fluid and esophageal thickening appear to be sufficiently diagnostic to eliminate the need for oral contrast material. Our data suggest that CT is useful for suggesting the diagnosis of esophageal perforation in situations in which the signs and symptoms are complicated or confusing. CT is the best technique for defining the paraesophageal manifestations of esophageal rupture and may have a role in selecting patients for medical management.

6. Faling U, Pugatch AD, Robbins AH. Case report: the diagnosis of unsuspected esophageal perforation by computed tomography. Am J Med Sci 1981 281:31-34 7. Endicott JN, Molony TB, Campbell G, Bartels U. Esophageal perforations: the role of computerized tomography in diagnosis and management decisions. Laryngoscope 1 986;96:751 -757

8. Backer CL, Lo Cicero J ill, Hartz AS, Donaldson

JS, Shields T. Computed

tomography in patients with esophageal perforation. Chest 1990;98: 1078-1 080 9. vennos AD, Templeton PA. Pneumopericardium secondary to esophageal carcinoma. Radiology 1992;182:1 31-132 10. Attar 5, Hankins JR. Suter CM, Coughlin TA, Sequeira A, McLaughlin JS. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990;
50:45-51

11 . White AK, tions. Am 12. Pate JW, rupture of

47:689-692

Morris

DM. Diagnosis

and management

of esophageal

perfora-

Surg1992;58:112-119
Walker WA, Cole FH Jr. Owen EW, Johnson the esophagus: a 30-year experience. Ann WH. Spontaneous Thorac Surg 1989;

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