GI Radiology > Esophagus > Structural Abnormalities

Structural Abnormalities of the Esophagus

Perforation

Untreated thoracic esophageal perforations have a near 100% mortality rate because of the fulminant mediastinitis that occurs afterwards. Perforation of the cervical esophagus is more common and has a lower mortality rate, 15%. In either case, early detection is important in order for prompt surgical intervention. Perforation can be due to iatrogenic causes (i.e. endoscopic procedures, pneumatic dilatation balloons, nasogastric tubes, endotracheal tubes), foreign bodies, trauma, or spontaneously (Boerhaave's syndrome-see next section).

Clinical
Cervical perforation often occurs as a complication of endoscopy. Patients may present with dysphagia, neck pain, fever, or subcutaneous emphysema in the neck. Cervical esophageal perforations heal with conservative treatment with antibiotics, but larger perforations may require cervical mediastinotomy with open drainage to prevent abscess formation.

Radiological findings
On plain films, subcutaneous emphysema may be visible on AP or lateral films of the neck. Air may also dissect into the chest and produce a pneumomediastinum. Lateral films of the neck may reveal widening of the prevertebral space, anterior deviation of the trachea, or a retropharyngeal abscess with an air-fluid level. If a cervical perforation is suspected on plain film, the study should be followed up with a water-soluble contrast study.
Water-soluble contrasts are rapidly absorbed from the mediastinum, whereas barium has been shown to excite an inflammatory response with fibrosis. However water-soluble contrasts may miss 15 to 25% of perforations because they are less radiopaque than barium. On the esophogram, one would look for localized extravasation of contrast medium into the neck or mediastinum.

In image "A", this frontal view of the chest shows evidence of mediastinal and subcutaneous emphysema with pneumonitis. Image "B" reveals an esophagram with extravasation of contrast from the esophagus.

Clinical
Thoracic perforation often present with the classic triad of vomiting, lower thoracic chest pain and subcutaneous emphysema. Refluxed stomach acid or swallowed food/saliva may enter the mediastinum and cause severe mediastinitis. If no subcutaneous emphysema is present, thoracic esophageal perforations are often mistaken as perforated peptic ulcers, MI, spontaneous pneumothorax, pancreatitis, dissecting aortic aneurysm, or mesenteric infarction. After 24 hours, the mortality rate for thoracic perforation approaches 70%. Unlike cervical perforations, thoracic perforations are treated immediately with surgery and drainage.

Radiological findings
On plain films, a widened mediastinum and pneumomediastinum may be present. Also, approximately 75% of thoracic esophageal perforations are associated with a pleural effusion or hydropneumothorax. Left pleural effusions often occur because of irritation of the adjacent parietal pleura and pulmonary parenchyma. Hydropneumothorax can occur if the mediastinal pleura ruptures and gas and fluid may enter the pleural space directly from the mediastinum.
On esophagram, contrast media is usually seen extravasating from the left lateral aspect of the distal esophagus because most thoracic perforations occur near the gastroesophageal junction.

 

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