From the Guidelines
Diagnosing esophageal rupture requires a high index of suspicion based on clinical presentation and prompt imaging studies, with contrast-enhanced computed tomography (CT) and CT esophagography being the imaging examination of choice, as recommended by the World Journal of Emergency Surgery in 2019 1. The diagnosis should be considered in patients with severe chest or epigastric pain following vomiting, retching, or instrumentation of the esophagus. Initial evaluation includes:
- Chest X-ray, which may show pneumomediastinum, pleural effusion, or subcutaneous emphysema, though it can be normal in early presentations
- Contrast esophagography using water-soluble contrast (such as Gastrografin) is a useful diagnostic test, demonstrating contrast extravasation at the rupture site
- CT scan with oral contrast provides excellent visualization of mediastinal air, pleural effusions, and sometimes the actual perforation site Laboratory findings often show leukocytosis, but are nonspecific. Endoscopy should be used cautiously as it risks extending the perforation, but can be useful in patients with suspected esophageal rupture and doubtful CT findings, as stated in the World Journal of Emergency Surgery in 2019 1. Pleural fluid analysis showing food particles, elevated amylase, or pH <6.0 strongly suggests esophageal rupture. Time is critical in diagnosis, as mortality increases significantly when treatment is delayed beyond 24 hours, with complications including mediastinitis, sepsis, and multiorgan failure, highlighting the importance of immediate evaluation in patients with suspicious symptoms following a potential triggering event, as emphasized in the World Journal of Emergency Surgery in 2019 1. The current recommendations rely on extensive review of the literature and expert opinion, and it is recommended that definitive management of esophageal emergencies should be undertaken in specialized centers with multispecialty expertise available round the clock 1.
From the Research
Diagnostic Features of Esophageal Rupture
The diagnosis of esophageal rupture can be challenging, but several studies have identified key features that can aid in diagnosis. These include:
- Toxic appearance, pleural effusion, pneumothorax, elevated white blood cell count, azotemia, and hypoxia, which are all positively associated with esophageal rupture 2
- Chest pain after vomiting, which is a common symptom of spontaneous esophageal rupture 3
- Abnormal chest X-ray findings, such as pneumothorax and/or pleural effusion, which are present in the majority of cases 2
Imaging Studies for Diagnosing Esophageal Rupture
Several imaging studies can be used to diagnose esophageal rupture, including:
- CT esophagography, which has been shown to have a high negative predictive value (NPV) and sensitivity for diagnosing esophageal perforation 4, 5
- Fluoroscopic esophagography, which is considered the gold standard for diagnosing esophageal rupture, but may not provide additional information beyond CT esophagography 4, 6
- CT with oral contrast material, which can help identify esophageal perforation and has a higher positive predictive value (PPV) than CT without oral contrast material 4
Diagnostic Performance of CT Esophagography
CT esophagography has been shown to have good diagnostic performance in patients with suspected esophageal rupture, with:
- Sensitivity of 77.7% and specificity of 94.3% 5
- Positive likelihood ratio (LR) of 14 and negative LR of 0.24 5
- A predictive model that includes variables such as age, leakage of contrast media, extraluminal air or fluid collections, esophageal wall thickening, and left pneumothorax or pleural effusion can help predict rupture 5