Esophageal Rupture Workup

  • Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Nov 21, 2011
 

Laboratory Studies

  • Diagnosis depends on a high index of clinical awareness and relies on confirmatory radiographic findings. However, order lab tests to establish baselines and to help with follow-up care.
  • Complete blood count (CBC): Evidence of leukocytosis is commonplace for almost all esophageal perforations.
  • pH level: Esophageal perforations with penetrance into the pleural cavity have pH levels less than 7.2.
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Imaging Studies

  • Although findings may not include significant results if taken early, order urgent posteroanterior and lateral chest and upright abdominal radiographs (diagnostic in 90% of cases) to look for the following conditions:
    • Hydrothorax (usually on the left)
    • Hydropneumothorax
    • Pneumothorax
    • Pneumomediastinum
    • Subcutaneous emphysema
    • Mediastinal widening without emphysema
    • Subdiaphragmatic air
    • Pleural effusions (These are more common on the left but can occur bilaterally and, rarely, only of the right.)
  • Gastrografin (water-soluble contrast) and/or barium esophagram following plain radiography may be performed to look for extravasation of contrast and location and extent of rupture/tear (see image below). Twenty-two percent of patients considered to have a strong likelihood of esophageal perforation whose water-soluble contrast studies reveal negative results are found to have esophageal perforation on barium contrast studies. Water-soluble contrast esophagram from a patient wWater-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
  • CT scanning may be performed if contrast esophagraphy cannot be performed, cannot localize rupture, or is nondiagnostic.[12] If the patient has been sedated, delay contrast studies pending the return of the gag reflex. 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 eMedicine Radiology article Esophagus, Tear.
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Other Tests

  • Other tests depend on the results of esophagram.
    • MRI, CT scanning, or both may be indicated for dissection of aorta.
    • Ventilation/perfusion (V/Q) and/or CT scanning of the lungs may reveal pulmonary embolism.
    • ECG may exclude myocardial infarction or associated cardiac abnormalities.
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Diagnostic Procedures

  • Esophagogastroduodenoscopy is not recommended for acute esophageal rupture.
  • Thoracentesis, 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  Clinical Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois College of Medicine; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Director, Adult ECMO, Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, American Medical Writers Association, Chicago Medical Society, Illinois State Medical Society, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

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, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Thomas E Kowalski, MD  Assistant Professor, Department of Medicine, Director, Gastrointestinal Endoscopy Unit, Thomas Jefferson University, Consulting Staff, Thomas Jefferson University Hospital

Disclosure: Nothing to disclose.

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, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Benson B Roe, MD  Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center

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, and Society of University Surgeons

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

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

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

Disclosure: Nothing to disclose.

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