Usually from left side of distal thoracic esophagus
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Chest film
Left side pleural effusion or hydropneumothorax
Radiolucent streaks of gas along aorta or in neck
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Esophagography with nonionic, water-soluble contrast agent
Shows extravasation of ingested or injected (through nasogastric tube) contrast medium
From left side of esophagus, just above gastroesophageal (GE) junction
If initial study with water-soluble contrast medium fails to show leak, examination must be repeated immediately with barium to detect subtle leaks
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CT
Extraluminal gas &/or oral contrast medium in lower mediastinum &/or upper abdomen
TOP DIFFERENTIAL DIAGNOSES
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Pulsion diverticulum (epiphrenic)
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Iatrogenic (postinstrumentation) injury
CLINICAL ISSUES
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Accounts for 15% of total esophageal perforation cases
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Prognosis for large perforation
After 24 hours without treatment: Mortality = 70%
After immediate surgical drainage: Good
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Treatment
Drains in esophagus, mediastinum, pleural space, &/or abdomen
TERMINOLOGY
Definitions
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Spontaneous distal esophageal perforation following vomiting or other violent straining
IMAGING
General Features
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Best diagnostic clue
Extraluminal gas and contrast material in lower mediastinum surrounding esophagus
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Other general features
Sudden increase in intraluminal pressure leads to full-thickness esophageal perforation
Left side of distal thoracic esophagus
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Most vulnerable (due to lack of supporting mediastinal structures)
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Vertical, full-thickness tear, 1-4 cm long
Related
Diagnostic Imaging_ Gastrointes - Michael P Federle