What type of computed tomography (CT) scan is recommended for diagnosing an esophageal tear?

CT Imaging for Esophageal Tear

Order a contrast-enhanced CT of the chest and abdomen with oral contrast (CT esophagography) as the primary imaging modality for suspected esophageal perforation or tear.

Recommended CT Protocol

CT esophagography should be performed with both intravenous and oral contrast to maximize diagnostic accuracy 1, 2, 3. The specific protocol includes:

• Oral contrast administration: Use water-soluble contrast (such as Gastrografin) rather than barium, as barium can coat the mucosa and impair subsequent endoscopic visualization if needed 4, 5
• IV contrast: Administer 2-3 mL/s of nonionic contrast agent (2 mL/kg) with 18-25 second acquisition time and 90-second scan delay 4
• Timing: Perform CT 3-6 hours after suspected injury when possible 4
• Coverage area: Include neck, chest, and abdomen to assess the full extent of injury and complications 4

Diagnostic Performance

CT esophagography demonstrates superior sensitivity (100%) compared to fluoroscopic esophagography (77.8%) for detecting esophageal perforation 2. The negative predictive value of CT is 100%, meaning a negative CT effectively rules out clinically significant perforation 2. CT with oral contrast has a positive predictive value of 38.5% versus 26.7% without oral contrast 2.

CT outperforms traditional contrast esophagography, which can miss up to 30% of small esophageal perforations 1, 6. More importantly, CT esophagography has been shown to be at least equal to if not superior to fluoroscopic evaluation for esophageal injury 3.

Key CT Findings to Identify

The radiologist should look for these critical findings that indicate esophageal perforation 1, 7, 8:

• Absence of post-contrast wall enhancement: The most important sign of transmural necrosis requiring emergency surgery 4
• Extraluminal air: Present in 97% of perforations, most useful finding 4, 7, 8
• Periesophageal fluid collections: Seen in 89-92% of cases 4, 8
• Extraluminal oral contrast: Direct evidence of leak 7, 2
• Esophageal wall thickening: Present in 72-75% of perforations 4, 8
• Pleural effusion or pneumothorax: Seen in 75% of cases 8
• Mediastinal fat stranding: Uniformly present in Grade II injuries 4

CT Grading System for Caustic/Transmural Injuries

A four-stage CT classification helps guide management 4:

• Grade I: Homogenous wall enhancement, no edema or stranding
• Grade IIa: Internal mucosal enhancement with hypodense thickened wall ("target" appearance)
• Grade IIb: Fine rim of external wall enhancement only, necrotic mucosa doesn't enhance
• Grade III: Complete absence of post-contrast wall enhancement (indication for emergency surgery)

When to Add Endoscopy

Flexible endoscopy should be performed as an adjunct to CT only in specific situations 1:

• CT unavailable or contraindicated (renal failure, iodine allergy)
• CT findings are equivocal or uncertain
• Pediatric population (to minimize radiation exposure)
• Combined with CT, endoscopy allows accurate diagnosis in >90% of cases and alters surgical management in 69% of patients 1

Critical caveat: Use low-flow CO2 insufflation rather than air during endoscopy to minimize risk of enlarging the perforation and worsening mediastinal contamination 1, 6.

Why Not Fluoroscopic Esophagography?

Fluoroscopic esophagography should NOT be the initial study despite being listed in older ACR appropriateness criteria 2, 3. Multiple studies demonstrate:

• Lower sensitivity (77.8%) compared to CT (100%) 2
• Misses up to 30% of small perforations 1, 6
• Provides no additional diagnostic information beyond CT 2
• Does not change clinical management when CT is already performed 2
• Cannot assess extraesophageal complications as well as CT 3

Critical Timing Considerations

Time is the most important survival predictor, with mortality under 10% if diagnosed and managed within 24 hours versus 30% after this timeframe 1. Therefore:

• Perform CT esophagography emergently when esophageal perforation is suspected
• Do not delay imaging with less sensitive modalities
• CT can be performed rapidly without direct radiologist supervision 3

Common Pitfalls to Avoid

• Do not rely on plain radiographs alone: They have a false-negative rate up to 47% 4
• Do not assume negative CT rules out all perforations: CT can miss up to 30% of very small perforations, so maintain clinical suspicion 1
• Do not use barium: It impairs subsequent endoscopy and is contraindicated in perforation 4
• Do not perform CT without oral contrast: This reduces positive predictive value from 38.5% to 26.7% 2
• Do not order fluoroscopic esophagography after CT: It adds no diagnostic value 2