Esophageal perforation

Perforation
des Ösophagus bei Ösophaguskarzinom: Im Röntgenbild des Thorax sieht man ein Mediastinal- / Weichteilemphysem. Gut zu erkennen ist die bandförmige Aufhellung um den Aortenbogen.
Wikipedia • CC BY-SA 4.0
Infant with
hematemesis who had an unsuccessful nasogastric tube placementCXR AP shows air outlining the heart in the pericardial space, air outlining the thymus in the mediastinum, and air in the bilateral pleural spaces.The diagnosis was pneumopericardium, pneumomediastinum, and pneumothorax due to esophageal perforation from traumatic nasogastric tube placement. A subsequent esophagram did not demonstrate a leak.
pediatricimaging.org • CC-by-nc-sa 4.0
Imaging of
the oesophagus: beyond cancer. Complication of food impaction with tear of oesophagus during chicken bone extraction. a Pre-contrast axial image of the thorax demonstrates a markedly enlarged oesophagus which is high in density (*) when compared to the adjacent blood pool in the aorta (findings consistent with hematoma). b Post-contrast imaging of the same patient demonstrates areas of active contrast extravasation (arrows) within a markedly enlarged and abnormal appearing oesophagus. Clinical note, patient subsequently had multiple episodes of hematemesis
insightsimaging.springeropen.com • Open Access
Esophageal
emergencies: another important cause of acute chest pain. Esophageal perforation. a, b Iatrogenic esophageal perforation. Eighty-year-old woman with chest pain after transesophageal echocardiography. Axial (a) and sagittal (b) CT images show a dilated and blood-filled upper esophagus (asterisk) contiguous with a large posterior hematoma containing multiple locules of gas (long arrow). Extensive hemo-pneumomediastinum (dashed arrow), small bilateral pleural effusions (short arrow), and subcutaneous emphysema in the lower neck (arrowhead) are seen. c, d Boerhaave syndrome. Eighty-seven-year-old woman with epigastric and back pain after forceful vomiting. c Axial CT image at the gastroesophageal junction shows extraluminal gas surrounding the lower esophagus (arrow). Bilateral pleural effusions (asterisk). d Single contrast esophagography demonstrates luminal narrowing and irregularity of lower esophagus (arrow) with large contrast extravasation into the left pleural space (asterisk). e Traumatic esophageal perforation. Twenty-five-year-old male with gunshot wound to the chest. Axial CT image shows a bullet tract from right axilla to the left upper hemithorax (dashed arrow) resulting in bilateral pneumothoraces (not shown), left hemothorax (asterisk), and pulmonary contusion and laceration in the bilateral upper lobes (arrow). There is esophageal thickening and indistinctiveness with a small hematoma (circle) representing esophageal injury/perforation
insightsimaging.springeropen.com • CC-by-4.0
Esophageal
emergencies: another important cause of acute chest pain. Malignancy-induced esophageal perforation and esophago-bronchial fistula. Forty-nine-year-old male with recently diagnosed esophageal cancer presenting with chest pain. a Axial CT image shows circumscribed mass of the lower esophagus consistent with esophageal cancer (short black arrow). The esophagus is perforated into the right lower lobe containing debris and gas (white long arrow). The medial basal segment bronchus is encased by the debris (arrowhead). An esophageal stent was urgently placed. b Esophagography obtained 2 weeks after placing the esophageal stent shows an esophago-bronchial fistula (arrow). Appropriate position of esophageal stent (asterisk) is seen
insightsimaging.springeropen.com • CC-by-4.0
Premature
newborn with abdominal distension after nasogastric tube placementSupine AXR (above) shows increased lucency in the upper abdomen. The cross-table lateral AXR (below) shows air between the anterior abdominal wall and the bowel. The nasogastric tube follows a very straight course and does not curve towards the stomach. Note on both views that the tip of the nasogastric tube does not project over the stomach. US performed subsequently showed the tip of the nasogastric tube was in the retroperitoneum and not in the stomach.The diagnosis was perforation of the esophagus during nasogastric tube placement. In the operating room the pneumoperitoneum was found to be due to an ileal perforation.
pediatricimaging.org • CC-by-nc-sa 4.0
Perforation
des Ösophagus bei einer Endoskopie bei Ösophaguskarzinom. Das Kontrastmittel tritt an der Perforationsstelle an der Tumorstenose in das ösophageale Lumen und in das Mediastinum (vorne) über. Prästenotische Dilatation.
Wikipedia • CC BY-SA 4.0
The
anatomical compartments and their connections as demonstrated by ectopic air. Local sources of pneumomediastinum. a, b Spontaneous pneumomediastinum due to prolonged and forceful Valsalva manoeuvres in 21-year-old man. Axial CT scan with “lung window” demonstrates the Macklin effect: air is seen along the perivascular and peribronchial fascial sheaths (a), continuous to the mediastinum (red star) (b). c Oesophageal perforation by fishbone complicated by mediastinitis in a 61-year-old woman. Axial CT scan after oral iodinated contrast ingestion, distending the oesophagus (red square); extraluminal air bubbles (red arrows) are seen in mediastinum together with increased mediastinal fat attenuation, as well as multiple reactive lymph nodes. Normal permeable airways are seen (blue triangle) at level of carina
insightsimaging.springeropen.com • Open Access
Preschooler
who hit their throat on the rim of a plastic chair and now has throat pain and hemoptysis. Sagittal CT without contrast of the neck (left) shows pneumomediastinum anterior to the spine. Lateral image from an esophagram (right) shows contrast extravasating outside the esophagus at the level of C4.The diagnosis was esophageal perforation due to blunt trauma.
pediatricimaging.org • CC-by-nc-sa 4.0
Spondylodiscitis
• Spondylodiscitis and epidural abscess caused by esophageal perforation due to a metallic stent - Ganzer Fall bei Radiopaedia
O'Donnell C, Spondylodiscitis and epidural abscess caused by esophageal perforation due to a metallic stent. Case study, Radiopaedia.org (Accessed on 23 Jan 2023) https://doi.org/10.53347/rID-35525 • CC by-nc-sa 3.0 (modified)
Esophageal
perforation • Esophageal cancer complicated by oesophagopulmonary fistula and lung abscess - Ganzer Fall bei Radiopaedia
Farzam F, Esophageal cancer complicated by oesophagopulmonary fistula and lung abscess. Case study, Radiopaedia.org (Accessed on 01 Sep 2023) https://doi.org/10.53347/rID-69780 • CC by-nc-sa 3.0 (modified)
Esophageal
perforation • Iatrogenic esophageal perforation with esophageal-pleural fistula-CT esophagography - Ganzer Fall bei Radiopaedia
Saber M, Iatrogenic esophageal perforation with esophageal-pleural fistula-CT esophagography. Case study, Radiopaedia.org (Accessed on 01 Sep 2023) https://doi.org/10.53347/rID-88965 • CC by-nc-sa 3.0 (modified)
Radiopaedia • CC-by-nc-sa 3.0 • de

Esophageal perforation is a rare but serious medical emergency with a very high mortality rate, especially if the diagnosis is delayed.

Epidemiology

Most patients are in their sixties with a slight male predominance .

Clinical presentation

If a perforation is not detected during the procedure or operation, the patient may present with neck, chest or epigastric pain, dysphagia or dyspnea although symptoms asides from chest pain (present in 70%) are quite variable . Subcutaneous emphysema may also be present . There is risk of bleeding and infection .

Pathology

The lack of a serosal layer may make the esophagus more susceptible to injury than other parts of the gastrointestinal tract .

Etiology
  • iatrogenic
  • trauma: both blunt (crush-type injury) and penetrating
    • occurs in <0.1% of blunt chest trauma
  • foreign body ingestion
  • corrosive material ingestion
  • esophageal cancer
  • spontaneous rupture post vomiting (Boerhaave syndrome)

Radiographic features

Plain radiograph

Possible clues on chest radiographs include:

Fluoroscopy
  • most sensitive within the first 24 hours
  • patient examined semi-supine (~20 degrees) on the fluoroscopy table
  • a low-osmolar water-soluble agent should be used initially as barium can cause mediastinitis 
  • esophageal perforation may be represented as mucosal irregularity or extraluminal oral contrast leak
  • some authors suggest the use of small amounts of low or high concentrations of barium if no leak is evident on initial screening with water-soluble contrast
CT

The role of CT is usually to look for stigmata of perforation when fluoroscopy is equivocal, and there is persisting suspicion of perforation. These include:

  • extraluminal gas locules in the mediastinum or abdominal cavity, adjacent to the esophagus are highly suggestive
  • pleural or mediastinal fluid
  • pneumomediastinum or pneumothorax
  • pericardial or pleural effusions can be seen

Water-soluble oral contrast can be administered 20 minutes before scanning to demonstrate extraluminal contrast leak. Intravenous contrast is usually administered to delineate the esophageal wall (25 - 60-second delay) .

Treatment and prognosis

There is a high mortality rate, estimated between 25 to 50% in some series and this is significantly increased if the diagnosis is delayed beyond 24 hours .

The rarity of this condition means that treatment is not well established and options include surgical or endoscopic management vs. medical management .

Complications
Siehe auch:
und weiter:
Assoziationen und Differentialdiagnosen zu Ösophagusperforation:
Ösophaguskarzinom
 
Wikipedia • CC BY-SA 3.0
ösophagotracheale
Fistel
Wikipedia • CC BY-SA 4.0
Ösophagusstents
 
Wikipedia • CC BY-SA 3.0
Boerhaave-Syndrom
 
www.eurorad.org • CC by-nc-sa-4.0
Ösophagusruptur
 
pediatricimaging.org • CC-by-nc-sa 4.0
scheinbares
zweites Lumen des oberen Ösophagus
Wikipedia • CC BY-SA 4.0
intramurale
Dissektion des Ösophagus
insightsimaging.springeropen.com • CC-by-4.0