Esophageal Perforation

Published on 18/07/2015 by admin

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Last modified 22/04/2025

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 Majority are due to esophageal instrumentation

image Confirmed by contrast esophagram or CT, which are complementary
• Cervical esophageal perforation (EP)

image Subcutaneous or interstitial emphysema; neck and mediastinum
image Consider perforation of Zenker diverticulum
• Thoracic EP

image Chest film: Pneumomediastinum, pleural effusion
• EP of intraabdominal segment of distal esophagus

image Abdominal plain film: Pneumoperitoneum
• EP near GE junction

image Extravasated contrast from left lateral aspect of distal esophagus into mediastinum, sometimes pleural space, and rarely abdomen (never abdomen alone)
• CT shows extraesophageal air in almost all cases, fluid and contrast medium in most
• Intramural EP: Extravasated gas and contrast remain within esophageal wall

image Much better prognosis
• Esophagography: Technique

image Esophagram: Videofluoroscopic and rapid sequence filming
image Nonionic water-soluble contrast media (e.g., Omnipaque) initially, followed with barium if no leak or fistula seen
image Barium (or CT) may detect small leak not visible initially

TOP DIFFERENTIAL DIAGNOSES

• Esophageal diverticulum
• Esophageal ulceration
• Boerhaave syndrome
• Postoperative state, esophagus
• Tracheobronchial aspiration
image
(Left) Barium esophagrams reveal a tight stricture at the gastroesophageal (GE) junction image. Due to concern for Barrett metaplasia or early cancer, an endoscopic biopsy of the lesion was performed following balloon dilation of the stricture.

image
(Right) Postbiopsy esophagram in the same patient illustrates a focal intramural barium collection image, indicating a localized perforation. These intramural perforations will usually heal spontaneously.
image
(Left) Esophagram in a 62-year-old man with a history of laparoscopic hiatal hernia repair, now presenting with subsequent chest pain and fever, demonstrates mediastinal image and abdominal image extraluminal collections of gas and contrast material.

image
(Right) Axial CECT in the same patient reveals mediastinal image and abdominal image extraluminal collections of gas and contrast material, indicating perforation near the GE junction. Surgical drainage was successful.

TERMINOLOGY

Abbreviations

• Esophageal perforation (EP)

Synonyms

• Esophageal rupture or transection

Definitions

• Transmural esophageal tear

IMAGING

General Features

• Best diagnostic clue

image Diagnosis depends on high degree of suspicion and recognition of clinical features

– Confirmed by contrast esophagram or CT
• Location

image Cervical EP: Posterior wall of esophagus at level of cricopharyngeus muscle

– Or through Zenker diverticulum
image Thoracic EP: At or near gastroesophageal (GE) junction

– Areas of anatomic narrowing, sites of extrinsic compression by aortic arch or L main bronchus
image At or above benign or malignant strictures
image Site of ruptured anastomosis or after esophageal surgery

Radiographic Findings

• Radiography

image Cervical EP: Anteroposterior, lateral films of neck

– Subcutaneous or interstitial emphysema
– Lateral film: Widening of prevertebral space
– Retropharyngeal abscess; mottled gas, air-fluid level
– Air may dissect along fascial planes from neck into chest, pneumomediastinum, or vice versa
image Thoracic EP: Chest radiograph

– Pneumomediastinum

image Radiolucent gas streaks along lateral border of aortic arch, descending aorta
– V-shaped radiolucency seen through heart
– Sympathetic left pleural effusion; atelectasis in basilar segment
– Pleural effusion, hydropneumothorax, localized pneumonitis due to esophageal-pleural fistula
– Hydropneumothorax: On left (75%), on right (5%), bilateral (20%)
– Hydrothorax: Usually unilateral, right sided with upper-/mid-EP; left sided with distal EP
– EP of intraabdominal segment of distal esophagus

image Abdominal plain film: Pneumoperitoneum

Fluoroscopic Findings

• Esophagography: Determine site and extent of EP
• Intramural EP: Extravasated gas and contrast remain within esophageal wall

image Much better prognosis
• EP near GE junction

image Extravasated contrast from left lateral aspect of distal esophagus into mediastinum, sometimes pleural space, and rarely abdomen (never abdomen alone)
• Sealed-off EP: Self-contained extraluminal collection of contrast medium
• Larger EP: Free extravasation of contrast medium into mediastinum

image Extension along fascial planes superiorly or inferiorly

CT Findings

• Optimal definition of extraluminal manifestations
• Extraesophageal air in 92% of cases
• Extraluminal oral contrast in most
• Mediastinal fluid collections (92%): Periesophageal, pleural, pericardial
• Diffuse infiltration of mediastinal fat (mediastinitis)
• Esophagopleural fistula

Imaging Recommendations

• Protocol advice

image Esophagram: Videofluoroscopic and rapid sequence filming

– Nonionic water-soluble contrast media (e.g., Omnipaque) initially, followed with barium if no leak or fistula seen
– Water-soluble contrast agent may fail to detect 15-25% of thoracic EP, 50% of cervical EP

image Barium may detect small leak not visible initially
– CT may detect leaks missed by esophagram

DIFFERENTIAL DIAGNOSIS

Esophageal Diverticulum

• Mucosa-lined pouch; changes shape
• No free mediastinal gas or inflammation

Esophagitis, Reflux

• Mucosal inflammatory changes
• From reflux, infection, caustic ingestion, etc.

Boerhaave Syndrome

• Spontaneous distal EP; violent retching, vomiting
• Extraluminal gas/contrast material in lower mediastinum surrounding esophagus
• 1-4 cm, vertically oriented, linear tears on left lateral wall just above GE junction

Postoperative State, Esophagus

• Postesophagectomy anatomy can be misinterpreted

image Irregular contour near anastomosis site
• Intramural linear collections are common on esophagram following Heller myotomy

Tracheobronchial Aspiration

• Contrast material in trachea or bronchi
• Differentiate esophageal airway fistula from aspiration

image Initial swallow in lateral projection with video recording of hypopharynx should detect aspiration

PATHOLOGY

General Features

• Etiology

image Iatrogenic

– Instrumentation: Most common cause of EP
– Endoscopic procedures: 75-80% of all EP; rigid and fiberoptic endoscopy
– Biopsy, esophageal surgery, bouginage, breakdown of surgical anastomoses
– Sengstaken-Blakemore tubes (35%)
– Flexible endoluminal prosthesis (10%)
– Pneumatic balloon dilation (2-10%)
– Esophageal obturator airways (2%)
– Nasogastric or endotracheal tubes, feeding tubes

image Often perforate through abnormal esophagus (e.g., Zenker or pulsion diverticulum)
– Sclerosis therapy (Rx) for esophageal varices
– Radiofrequency ablation Rx for atrial fibrillation
image Trauma

– Penetrating injuries: Knife or bullet wounds
– Blunt trauma to chest or abdomen (rare)
image Foreign bodies

– Impacted bones, sharp objects, caustic agents
image Spontaneous

– Boerhaave syndrome
– ↑ intrathoracic pressure, coughing, weightlifting, childbirth, status asthmaticus, seizures
image Neoplastic

– Esophageal carcinoma, usually after instrumentation or biopsy

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Cervical EP: Acute onset dysphagia, neck pain, fever
image Thoracic EP: Sudden onset of excruciating substernal or lower thoracic chest pain
image Rapid onset of overwhelming sepsis, fever, tachycardia, hypotension, shock
image Dysphagia, increased oral secretions, respiratory distress soon after endoscopy
image Atypical chest pain, referred to shoulder or back; epigastric pain
• Other signs/symptoms

image Presence of “signal” hemorrhage from gastrointestinal (GI) tract; vascular trauma due to perforating object
image Severe mediastinitis if food, saliva, refluxed peptic acid enter mediastinum
• Clinical diagnosis may be mistaken (e.g., for angina)
• Diagnosis by contrast esophagography: 90% are positive

Demographics

• Age

image Any age; infants, children, and elderly are most affected
• Epidemiology

image Incidence of EP ↑ as endoscopic procedures become more frequent

Natural History & Prognosis

• Most serious and rapidly fatal type of perforation in GI tract
• Life-threatening: High morbidity, high mortality without intervention
• Underlying esophageal disease, diverticulum, cervical lordosis, osteophytes: ↑ risk
• Can be immediate or delayed for several days if due to dilation procedures
• Complications: Retropharyngeal abscess, sepsis, shock

image Mediastinitis, mediastinal abscess, pericarditis, pneumothorax, fistula (thoracic EP)
• Prognosis dependent on cause, location, and type of underlying esophageal disease
• Prognosis directly related to interval between perforation and intervention

image After 24 hours: 70% mortality rate (thoracic EP)
image If untreated, mortality rate nearly 100% for thoracic EP
• Better prognosis with cervical EP than thoracic

image Cervical: 15% mortality
image Thoracic: 25% mortality

Treatment

• Conservative: Parenteral fluids, antibiotics

image Limited esophageal injuries meeting proper selection criteria
image Small cervical EP
image Rarely, thoracic EP heals spontaneously without surgical intervention

– Especially if intramural or very localized
• Surgical

image Cervical esophageal perforation (EP): Cervical mediastinotomy, open drainage
image Thoracic EP: Immediate thoracotomy, primary closure of EP, mediastinal drainage
• Covered metallic stents for leaks and fistulas

image Growing in use
image May still require drain placement in mediastinum ± pleural space
• Nonsurgical interventional drainage techniques; transesophageal drainage of abscesses

DIAGNOSTIC CHECKLIST

Consider

• Clinical and radiographic signs of EP may be subtle

image Active investigation is needed to establish diagnosis

Image Interpretation Pearls

• Esophagram: Rapid sequence filming in multiple obliquities
• Esophagography and CT are complementary; either can “miss” perforation

image
(Left) Esophagram in a 54-year-old man with esophageal cancer and chest pain following endoscopic biopsy demonstrates a long, irregular, eccentric stricture of the distal esophagus image, characteristic of carcinoma. Focal extravasation of contrast image indicates perforation.
image
(Right) Film from an esophagram in a 67-year-old man with chest pain following repair of an epiphrenic diverticulum shows a persistent, linear, focal collection of contrast medium image, representing a small leak. This healed with antibiotic therapy alone.
image
(Left) Esophagram film in a patient with neck and chest pain following attempted placement of a feeding tube shows a retroesophageal (mediastinal) collection of gas and water-soluble contrast medium image. This resulted from perforation of a Zenker diverticulum by the feeding tube. The track image runs posterior and parallel to the course of the proximal esophagus.

image
(Right) Axial NECT in the same patient shows subcutaneous gas image, extraluminal gas, and contrast medium in the prevertebral region image.
image
(Left) Esophagram in a 58-year-old man with chest pain following endoscopic removal of an impacted food bolus shows perforation of the distal esophagus image with extravasation of contrast material and gas image into the upper abdomen and mediastinum and free air image under the diaphragm.

image
(Right) Axial NECT in the same patient shows free intraperitoneal gas image and extraluminal gas along the esophagus and proximal stomach image. The imaging findings are identical to those seen in Boerhaave syndrome.
image
Axial NECT shows extraluminal oral contrast medium in the upper abdomen following placement of a nasogastric tube that perforated the esophagogastric junction.

image
Esophagram shows a left mediastinal collection of contrast medium image following balloon dilatation for achalasia.
image
Esophagram shows a contained leak image following balloon dilatation of an esophageal stricture.

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