Best Initial Test for Esophageal Rupture
Contrast-enhanced CT with CT esophagography is the imaging examination of choice for suspected esophageal perforation, with 92-100% sensitivity and 100% negative predictive value, making it superior to fluoroscopic esophagography as the initial test. 1
Why CT is the Preferred Initial Test
CT outperforms fluoroscopic esophagography in the emergency setting:
- CT demonstrates 100% sensitivity compared to only 77.8% for fluoroscopic esophagography 2
- CT has 100% negative predictive value, meaning a negative CT reliably excludes esophageal perforation 2, 3
- Fluoroscopic esophagography has a false-negative rate up to 47% for esophageal injuries 4
- CT can simultaneously rule out life-threatening mimics like aortic dissection and esophageal intramural hematoma 1
Critical CT Findings That Indicate Esophageal Perforation
Look for these key findings on CT:
- Periesophageal fluid collections (present in 89-92% of perforations) 5
- Extraluminal air adjacent to the esophagus (present in 97% of perforations) 5
- Esophageal wall thickening with periesophageal infiltration (72-75% of cases) 5
- Mediastinal fat stranding 5
- Pneumomediastinum (91% of cases) 6
- Pleural effusion, pneumothorax, or hydrothorax 1
Optimal CT Protocol
Use oral contrast when possible:
- CT with oral contrast has higher positive predictive value (38.5%) compared to CT without oral contrast (26.7%) 2
- Water-soluble contrast (Gastrografin) is preferred over barium to avoid impairing subsequent endoscopy if needed 5
- Coverage should include neck, chest, and abdomen 5
- Perform imaging 3-6 hours after suspected injury when possible to assess full extent 5
When to Add Fluoroscopic Esophagography
Fluoroscopic esophagography adds minimal value after CT:
- Combining CT and fluoroscopic esophagography does not improve sensitivity, specificity, or predictive values beyond CT alone 2
- Consider fluoroscopic esophagography only when CT findings are equivocal or doubtful 1
- In select cases, contrast-enhanced esophagogram may provide useful information about the location and contained character of perforation 1
Role of Endoscopy
Reserve endoscopy for specific situations:
- Diagnostic endoscopy is useful when CT findings are doubtful 1
- Flexible endoscopy allows accurate diagnosis in >90% of cases and alters management in 69% of patients when CT is equivocal 5
- Endoscopy carries risk of enlarging the perforation and worsening contamination, limiting its use as first-line examination 1
Plain Chest Radiograph Limitations
Do not rely on plain radiographs alone:
- Plain chest X-ray has up to 47% false-negative rate for esophageal perforation 5
- Misses 85% of pneumomediastinum cases 5
- While indirect signs (pneumomediastinum, pleural effusion, subcutaneous emphysema) may be visible, they are insufficient for diagnosis 1
Critical Pitfalls to Avoid
Time is critical for survival:
- Mortality ranges 10-20% overall, but delay in treatment is the most important survival predictor 1
- Delaying treatment beyond 24 hours increases mortality from <10% to 30% 5
- Over 50% of cases have delayed diagnosis, making high clinical suspicion essential 1
- When CT shows no signs of esophageal perforation, routine esophagography is not necessary 5