Esophageal Rupture and Tears in Emergency Medicine Workup

  • Author: Corey M Long, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Apr 28, 2011
 

Laboratory Studies

  • Laboratory studies are of little value in confirming the diagnosis.
  • If a diagnostic thoracentesis is performed on a pleural effusion, the presence of food particles, pH < 6, or an elevated pleural fluid amylase are compatible with esophageal perforation.
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Imaging Studies

  • Chest radiographs can be very helpful in diagnosing esophageal perforation, with suggestive abnormalities reported in about 90% of cases. Pneumomediastinum and subcutaneous emphysema are often present an hour after the injury and are highly suggestive of perforation. Mediastinal air-fluid levels, pleural effusions (often left sided), free air under diaphragm, pneumothorax, and hydropneumothorax encompass later potential findings. The V sign classically seen in esophageal perforation is indicative of pneumomediastinum. Air outlines the left lower mediastinal border and medial left hemidiaphragm, forming a "V".[2]
  • Lateral neck radiographs may demonstrate air in the fascial planes early in cases of cervical perforations.
  • A contrast esophagogram should be performed in any patient with suspected perforation. Despite a modest sensitivity (60-75%), a water-soluble contrast agent (Gastrografin) should be the initial study of choice. A barium study should be undertaken immediately afterward should the initial study show no evidence of perforation. Barium has a higher sensitivity (90%) for detecting small perforations but may cause a severe inflammatory response in tissues, most notably a mediastinitis. Studies should be performed with the patient in the right lateral decubitus position.
  • See the image below.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).
  • A contrast-enhanced CT scan of the chest should be obtained if it is not possible to obtain a contrast esophagogram, if the esophagogram was negative despite a high clinical suspicion, or if seeking to evaluate for a more likely alternative diagnosis. Perforation may be suggested by mediastinal air, extravasated luminal contrast, periesophageal fluid collections, pleural effusions, or actual communication of an air-filed esophagus with an adjacent mediastinal air-fluid collection; definitive esophageal communication with outside structures is often difficult to visualize.
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Other Tests

  • Esophagoscopy often can be used to visualize perforations and is especially useful in acute traumatic perforations, but it is not appropriate when small mucosal tears are suspected, as insufflated air can cause further dissection of the perforation.
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Contributor Information and Disclosures
Author

Corey M Long, MD  Resident, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center

Corey M Long, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Ugo Anthony Ezenkwele, MD, MPH  Assistant Professor of Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center

Ugo Anthony Ezenkwele, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD  Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eugene Hardin, MD, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows a false tract emanating from the esophagus (arrow).
Nonenhanced CT scan through the mid esophagus in a patient with esophageal perforation after upper GI endoscopy shows leakage of oral contrast material (blue arrow) and air in the posterior mediastinum (red arrow).
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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