Esophageal Perforation

Published on 18/07/2015 by admin

Filed under Radiology

Last modified 18/07/2015

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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 

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