From the Guidelines
To rule out esophageal perforation, a contrast-enhanced CT scan of the chest with oral water-soluble contrast is the preferred imaging modality. This approach is supported by the World Journal of Emergency Surgery guidelines, which recommend computed tomography (CT) scan in patients with suspected perforation or other complications that may require interventional endoscopy or surgery 1. The CT protocol should include both mediastinal and lung windows to adequately visualize potential contrast extravasation, mediastinal air, pleural effusions, or mediastinal fluid collections that would suggest perforation.
The use of CT scans is further emphasized in the management of esophageal injuries, where it is considered the key exam in patients with suspected perforation or other foreign body-related complications 1. Additionally, the guidelines for esophageal perforations suggest that contrast-enhanced CT and CT esophagography is the imaging examination of choice 1.
Some key points to consider when using CT scans to rule out esophageal perforation include:
- The scan should extend from the thoracic inlet to the upper abdomen to fully evaluate the esophagus and surrounding structures.
- Water-soluble contrast is used instead of barium because if perforation is present, barium could cause severe inflammatory reactions in the mediastinum or pleural spaces.
- In cases where the initial CT with oral contrast is negative but clinical suspicion remains high, an esophagogram with fluoroscopic guidance may be performed as a complementary study to increase diagnostic accuracy.
- The sensitivity of CT scans for detecting esophageal perforation is high, ranging from 92-100%, making it a reliable diagnostic tool 1.
Overall, the use of contrast-enhanced CT scans with oral water-soluble contrast is the preferred method for ruling out esophageal perforation due to its high sensitivity and ability to provide detailed images of the esophagus and surrounding structures.
From the Research
Types of CT Scans Used to Rule Out Esophageal Perforation
- CT esophagography is used to evaluate esophageal perforation, and it has been shown to be at least equal to, if not superior to, fluoroscopic evaluation for esophageal injury 2.
- CT scans with oral contrast material can be used to rule out esophageal perforation, and they have a high negative predictive value (NPV) similar to that of fluoroscopic esophagography 3, 4.
- CT scans without oral contrast material can also be used, but they may have a lower positive predictive value (PPV) compared to CT scans with oral contrast material 3, 4.
CT Findings Indicative of Esophageal Perforation
- Pneumomediastinum, pleural effusion, pneumothorax, unexplained mediastinal fluid or stranding, esophageal wall air or frank esophageal wall disruption, and extraluminal oral contrast material are all indicative of esophageal perforation 5, 3, 4.
- The presence of extraluminal air is a particularly useful finding in diagnosing esophageal perforation 5.
- CT findings may be the first indication of esophageal perforation, especially in patients with atypical signs and symptoms 5, 3.
Diagnostic Utility of CT Scans
- CT scans have a high sensitivity and NPV for diagnosing esophageal perforation, making them a useful tool for ruling out the condition 3, 4.
- The combination of CT and fluoroscopic esophagography does not improve sensitivity, specificity, PPV, or NPV relative to using CT alone 3.
- CT esophagography allows for the diagnosis of extraesophageal abnormalities and incidental findings, making it a valuable tool in the evaluation of esophageal perforation 2.