767

0361-803X/93/1604-0767
American Roentgen Ray Society
Esophageal Perforation: CT Findings
Charles S. White1
Philip A. Templeton1
Safuh Attar2
Received October 19, 1992; accepted after revi-
sion December 2, 1992.
1Department of Radiology, University of Mary-
land Medical Center, 22 5. Greene St., Baltimore,
MD 21201. Address correspondence to C. S.
W hite.
2Department of Surgery, University of Maryland
Medical Center, Baltimore, MD 21201.
OBJECTIVE. Esophageal perforation is a life-threatening condition that can be
quickly diagnosed on the basis of findings on contrast esophagograms when the typ-
ical signs and symptoms of vomiting, chest pain, and subcutaneous emphysema
occur. If the clinical features are atypical, CT may be performed early in the clinical
course. Thus, recognition of the CT findings of esophageal perforation is important.
MATERIALS AND METHODS. W e reviewed the CT scans of 12 patients with esoph-
ageal 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, per-
iesophageal 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 manifestations of esophageal perforation. Extraesoph-
ageal air is the most useful finding. The CT findings may be the first indication of the
diagnosis.
AJR 1993;160:767-770
Esophageal perforation is a frequently catastrophic event that classically
causes vomiting, chest pain, and subcutaneous emphysema. W hen 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 symp-
toms 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. W e reviewed the CT scans of 12 patients
with esophageal perforation to evaluate the usefulness of CT for the diagnosis
and assessment of this condition.
Materials and Methods
W e reviewed the medical records and radiologic files of 38 patients with a discharge diag-
nosis of esophageal perforation from 1986 to 1992. Fourteen patients had CT scanning dur-
ing the course of their evaluation. Two patients were excluded because their CT scans were
obtained after a corrective surgical procedure. The remaining 12 patients form the basis of
this study. A report on one of these patients was published previously [9].
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768 WHITE ET AL. AJR:160, April 1993
The study population consisted of five men and seven women,
16-79 years old (mean, 46 years). The diagnosis of esophageal
perforation was confirmed by findings on contrast esophagograms
(10), at endoscopy (one), or at surgery (one). A review of the medi-
cal records and radiologic studies indicated that the causes of the
perforations were neoplastic (four), iatrogenic (three), idiopathic
(three), and traumatic (two). The four neoplastic perforations
included three primary esophageal cancers and one lung cancer
invading the esophagus. None of the affected patients had received
prior treatment. The three iatrogenic perforations included two
cases of postoperative rupture after primary esophageal repair of
traumatic esophageal perforation and a perforation after balloon
dilatation for achalasia. The site of perforation was the cervical
esophagus in three patients and the thoracic esophagus in nine.
All CT scans were obtained with General Electric 9800 (General
Electric Medical Systems, Milwaukee, W I), Somatom HiQ and Sie-
mens DRH (Siemens Medical Systems, Iselin, NJ), CGR (Paris,
France), or Pfizer (Columbia, MD) CT systems. Ten chest CT scans
consisting of contiguous sections 8 or 10 mm 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
oral contrast material.
Two thoracic radiologists reviewed the CT scans and arrived at a
final interpretation by consensus. They evaluated the scans for evi-
dence of focal esophageal thickening and of air or fluid in the medi-
astinum, pericardium, lower part of the neck, or pleural space. An
attempt was made to correlate the location of these abnormalities
with the location of the esophageal perforation.
The medical records were reviewed to determine the clinical set-
ting 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 the 12 patients in the study, the esophageal wall was
focally thickened in nine, normal in one, and poorly visual-
ized 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 medias-
tinal in six (Fig. 2), mediastinal and cervical in two, mediasti-
nal 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 sub-
carinal level shows esophageal thickening in
63-year-old man with spontaneous esophageal
perforation (arrow).
Fig. 2.-Extensive pneumomediastinum in
23-year-old woman with spontaneous esoph-
ageal perforation. CT scan at level of carina
shows large quantity of air in anterior mediasti-
num (arrow s).
Fig. 3.-Direct visualization of site of perfo-
ration with an esophagopleural fistula in 56-
year-old woman with esophageal cancer.
A , CT scan shows air track (arrow ) extend-
ing from esophagus into mediastinum.
B , CT scan immediately cephalic to A shows
track (arrow ) extends to pleural cavity.
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AJR:160, April 1993 ESOPHAGEAL PERFORATION 769
Fig. 4.-Neoplastic esophageal perforation
in 58-year-old woman with bronchogenic can-
cer invading esophagus.
A, CT scan at level of perforation shows soft-
tissue mass containing extraluminal air (ar-
row s). Perforation was confirmed by esopha-
gography. Esophagus cannot be detected as a
separate structure.
B , CT scan at level superior to A shows right-
sided paratracheal mediastinal adenopathy (ar-
row ), 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 sug-
gested 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 cervi-
cal esophagus laceration; the leak and abscess were diag-
nosed on the basis of CT findings. The site of the perforation
was localized on contrast esophagograms.
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 appro-
pniate medical and surgical intervention. Detection of the per-
foration 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, 10-
13], 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.
W hen these features are present, the diagnosis is con-
firmed by findings on an oral contrast study. The clinical fea-
tunes 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 mediastini-
tis. In such cases, the diagnosis of esophageal perforation
may not be considered initially.
Chest nadiognaphs may show pleural effusion, hydnopneu-
mothonax, 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 stan-
dard technique for diagnosing esophageal perforation and
can be performed with water-soluble contrast material fol-
lowed by barium. In most cases, the site 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 esopha-
gus or tracheobronchial tree or penetrating trauma. Addi-
tional CT findings such as esophageal thickening may allow
further characterization of the underlying process. Mediasti-
nal, cervical, pleural, or penicardial fluid is usually present
but is a less specific finding. Pleural effusions were most fre-
quently bilateral. The left-sided predominance of pleural effu-
sions 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 nonsurgi-
cal management. The most widely used criteria for consen-
vative 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 esoph-
ageal perforation, 12 of whom were treated medically, Shaf-
fer 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
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770 WHITE ET AL. AJR:160, April1993
options remains to be defined. A larger study with a prospec-
tive 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 diagnos-
tic 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 tech-
nique for defining the paraesophageal manifestations of
esophageal rupture and may have a role in selecting patients
for medical management.
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