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Esophageal Rupture Workup

  • Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
 
Updated: Mar 12, 2015
 

Laboratory Studies

Diagnosis of esophageal rupture depends on a high index of clinical awareness and relies on confirmatory radiographic findings. However, laboratory tests (eg, complete blood count [CBC] and pH test) should be ordered to establish baseline values and to help with follow-up care.

Evidence of leukocytosis on the CBC is commonplace for almost all esophageal perforations. Esophageal perforations with penetrance into the pleural cavity have pH levels lower than 7.2.

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Imaging Studies

Although diagnostic images may not yield significant findings if obtained early, posteroanterior and lateral chest and upright abdominal radiographs (diagnostic in 90% of cases) should be obtained on an urgent basis to look for the following conditions:

  • Hydrothorax - This will usually be on the left
  • Hydropneumothorax
  • Subcutaneous emphysema
  • Mediastinal widening without emphysema
  • Subdiaphragmatic air
  • Pleural effusions - These are more common on the left but can occur bilaterally and, in rare cases, on the right only

Water-soluble contrast (eg, diatrizoate meglumine – diatrizoate sodium) or barium esophagography following plain radiography may be performed to look for extravasation of contrast and to determine the location and extent of the rupture or tear (see the image below). In 22% of patients considered to have a strong likelihood of esophageal perforation whose water-soluble contrast studies reveal negative results, barium contrast studies reveal esophageal perforation.

Water-soluble contrast esophagogram from patient w Water-soluble contrast esophagogram from patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).

If contrast esophagography cannot be performed, cannot localize a rupture, or is nondiagnostic, computed tomography (CT) may be performed.[12] A study by Suarez-Poveda found CT esophagography to yield good diagnostic results in the setting of suspected esophageal rupture.[13]

If the patient has been sedated, contrast studies should be delayed until the gag reflex has returned. Look for the following signs:

  • Air in the soft tissue of the mediastinum surrounding the esophagus
  • Abscess cavities in the pleural space/mediastinum
  • Communication of the esophagus with mediastinal fluid collections

For more information on imaging of this condition, see Esophagus, Tear.

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Other Tests

Other tests may be considered, depend on the results of esophagography. Magnetic resonance imaging (MRI), CT, or both may be indicated for aortic dissection. Ventilation/perfusion (V/Q) scanning or CT of the lungs may reveal pulmonary embolism. Electrocardiography (ECG) may exclude myocardial infarction or associated cardiac abnormalities.

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Diagnostic Procedures

Esophagogastroduodenoscopy (EGD) is not recommended for acute esophageal rupture. Thoracocentesis, though rarely needed, may reveal acidic pH, elevated salivary amylase, purulent malodorous fluid, or the presence of undigested food in pleural aspirate, which help confirm the diagnosis.

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Contributor Information and Disclosures
Author

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Coauthor(s)

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

Yogesh Govil, MD, MRCP Consulting Staff, Department of Internal Medicine, Division of Gastroenterology, Crozer-Chester Medical Center

Yogesh Govil, MD, MRCP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Thomas Kowalski, MD 

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shreekanth V Karwande, MBBS Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center

Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD, MMM Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD, MMM is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Society of Thoracic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Benson B Roe, MD 

Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, Society of University Surgeons

Disclosure: Nothing to disclose.

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Water-soluble contrast esophagogram from patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
 
 
 
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