Esophageal Rupture Workup

Updated: Apr 09, 2019
  • Author: Dale K Mueller, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Workup

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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Plain Radiography

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
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Contrast Esophagography

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. [14]  A study by Suarez-Poveda found CT esophagography to yield good diagnostic results in the setting of suspected esophageal rupture. [15]

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, depending on the results of esophagography. Magnetic resonance imaging (MRI), CT, or both may be indicated for aortic dissection. Multidetector CT (MDCT) is increasingly being used in the setting of esophageal rupture. [16] 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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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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