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luoroscopic esophagography per-formed with water-soluble contrastagents is the study of choice for

suspected esophageal perforation [1, 2]. How-ever, fluoroscopic esophagography can be diffi-cult to perform in seriously ill patients andrequires patient transport to the fluoroscopysuite, and false-negative results may occur [1,3]. Because esophageal perforation is one ofseveral diagnostic considerations for patientswith chest pain, many patients with esophagealperforation may first undergo thoracic CT, re-quiring fluoroscopic esophagography to be per-formed as a separate examination. A method forevaluating patients with chest pain that providesevaluation for both esophageal perforation andmore common causes of acute chest pain is de-sirable. We report a CT technique designed tospecifically assess patients for esophageal per-foration that may be performed after routinethoracic helical CT. This technique, which useslow-osmolar IV contrast material as the oralagent, may obviate fluoroscopic esophagogra-phy, therefore expediting the evaluation of pa-tients presenting with chest pain.

Materials and Methods

Patient Population

Eleven patients with suspected esophageal perfo-ration underwent a specific thoracic CT protocol de-

signed to assess for esophageal perforation (helicalCT esophagography). Two patients were examinedusing thoracic helical CT after thoracic gunshotwounds; one patient, after blunt trauma; and six pa-tients, for atraumatic chest pain. One patient refusedfluoroscopic esophagography and underwent heli-cal CT esophagography to exclude anastomotic leakafter esophageal surgery. One patient underwent he-lical CT esophagography to assess for gastric-pul-monary fistula

after gastric pull-up surgery.

Helical CT Esophagography Technique

All patients were initially scanned with helicalCT from the thoracic inlet to the diaphragm using 5-mm collimation and 3-mm reconstruction incre-ments. On the initial scan, pneumomediastinum wasseen in nine patients. This finding raised suspicionfor esophageal perforation and prompted the perfor-mance of helical CT esophagography. Helical CTesophagography was performed to exclude postsur-gical anastomotic leak for the patient who refusedfluoroscopic esophagography. One patient had ne-crotizing pneumonia in the right upper lobe, and he-lical CT esophagography was performed to excludegastric-pulmonary fistula.

All patients received approximately 50 mL of anaqueous solution consisting of 10% IV iodinated con-trast material (Omnipaque 300 [iohexol], Nycomed),effervescent granules (sodium bicarbonate and tar-taric acid), and water either by rapidly drinking thesolution or by injection through a nasogastric tube.The granules were dissolved in 50 mL of water beforeconsumption; when the solution was injected via sy-ringe, care was taken not to draw any residual particu-

late into the syringe. Thoracic helical CT was thenperformed using the exact same parameters as thoseused for the initial scan without IV contrast material.

Medical records were reviewed for patientswith negative findings on CT esophagography, nofluoroscopic examination with contrast material,and neither surgical nor endoscopic confirmationof esophageal perforation (

n

= 4).

Results

The study group comprised eight male pa-tients and three female patients. The averageage of patients undergoing helical CT esopha-gography was 40.1 years (range, 16–84 years).

None of the patients aspirated the oral con-trast solution. The additional CT scans requiredfor CT esophagography added an average ofapproximately 4 min to the total examinationtime. Findings from studies were positive foresophageal perforation in five patients (Figs. 1and 2) and were negative in six patients. Fluo-roscopic esophagography confirmed esoph-ageal perforation in two patients with positiveCT findings. Four of the five patients with posi-tive CT findings underwent surgery, and esoph-ageal perforation was confirmed in all; in thefifth patient, perforation of the intrathoracicstomach (gastric-pulmonary fistula) was endo-scopically confirmed.

Two patients who had negative results onhelical CT esophagography underwent endos-

Helical CT Esophagography for the Evaluation ofSuspected Esophageal Perforation or Rupture

Farhan Fadoo

1

, Diego E. Ruiz

1

, Samuel K. Dawn

1,2

, W. Richard Webb

1

, Michael B. Gotway

1,2

Received September 11, 2003; accepted after revision November 11, 2003.

1

Department of Radiology, University of California, San Francisco, Box 0628, San Francisco, CA.

2

Department of Radiology, San Francisco General Hospital, 1001 Potrero Ave., Rm. 1X 55A, Box 1325, San Francisco, CA 94110. Address correspondence to M. B. Gotway.

AJR

2004;182:1177–1179 0361–803X/04/1825–1177 © American Roentgen Ray Society

Technical Innovation

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Fadoo et al.

copy, which did not reveal esophageal perfora-tion in either patient.

Medical records were available in three offour patients undergoing CT esophagogra-phy who did not undergo fluoroscopicesophagography, endoscopy, or surgery.These patients were alive and without clini-cal evidence of mediastinitis at hospital dis-charge at a mean of 11 days (range, 0–30days) after the CT examination.

Discussion

Esophageal perforation is a life-threateningcondition usually occurring as a complicationof upper endoscopy or as a result of thoracictrauma, esophageal neoplasm, or violent retch-ing. Morbidity and mortality are dependent onprompt recognition and proper clinical man-agement. Unfortunately, clinical signs ofesophageal perforation are unreliable, and di-agnosis requires imaging or endoscopic evalu-

ation [4]. However, many patients with chestpain syndromes are not initially suspected ofesophageal rupture and are first evaluated withthoracic CT. Findings from the initial CT ex-amination may then raise suspicion of esoph-ageal injury by showing mediastinal gas orfluid, esophageal thickening, or pleural effu-sion [2, 4–6].

Fluoroscopic esophagography with water-soluble contrast material is the examination ofchoice for suspected esophageal perforation orrupture [2]. However, fluoroscopic esophagog-raphy performed with water-soluble contrastagents may produce false-negative results in10–38% of patients [1, 4], and aspiration ofhypertonic oral contrast solution may precipi-tate pulmonary edema [7]. Because false-nega-tive results may occur, a second fluoroscopicesophagogram obtained with high-density bar-ium is recommended to definitively excludeesophageal perforation [1]. This second exam-ination results in additional radiation exposure,additional cost, and further delays in clinicalmanagement. Finally, although the inert natureof barium generally implies that aspiration ofthis contrast material is not associated withdeleterious effects [7], recent evidence sug-gests that barium aspiration may produce se-vere pulmonary inflammation [8].

Many patients suspected of esophagealperforation are critically ill, and numerousphysical and practical obstacles are inherentin the transfer of such patients to the fluoros-copy suite. The need for the radiologist to

A B

Fig. 1.—17-year-old girl with gunshot wound to chest.A, Axial contrast-enhanced thoracic CT scan obtained after IV contrast injection but before oral administration of dilute IV con-trast medium shows right periesophageal air collection (arrow).B, Axial thoracic CT scan obtained after administration of dilute IV contrast medium through patient’s nasogastric tube showsfocus of pneumomediastinum (arrow) has filled with administered oral contrast agent, confirming esophageal perforation.

A B

Fig. 2.—16-year-old boy with gunshot wound to neck and chest.A, Axial contrast-enhanced thoracic CT scan obtained after IV contrast injection but before oral administration ofdilute IV contrast medium shows irregular gas collection (arrow) adjacent to right aspect of cervical esophagus.B, Axial thoracic CT scan obtained after administration of dilute IV contrast medium through patient’s nasogas-tric tube shows irregular gas collection (arrow) has filled with administered oral contrast agent, confirmingesophageal perforation.

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perform fluoroscopic esophagography maycreate further delay and cost.

Helical CT offers several advantages overfluoroscopic esophagography examinations [2,4–6]. Helical CT esophagography can be per-formed after an initial thoracic CT scan is ob-tained to exclude other causes of chest pain,obviating transport of seriously ill patients tothe fluoroscopy suite. The use of diluted low-os-molar IV contrast medium ensures that pulmo-nary edema will not result if the oral contrastmedium is aspirated [7] and low-osmolar IVcontrast medium that reaches extraluminal softtissues through a perforated viscus or rupturedvessel has not been associated with deleteriouseffects [7]. Helical CT can readily detect thesmall periesophageal air collections that indi-cate the presence of esophageal perforationmore readily than fluoroscopic esophagogra-phy; such air collections may be the most use-ful finding for suggesting the presence ofesophageal rupture [4, 5]. Finally, helical CTesophagography is easy to perform, and CTtechnicians and nurses can readily be trainedin its use. Once trained, CT technologists canperform helical CT esophagography withoutdirect radiologist supervision, allowing the ra-diologist to attend to other duties or remainoff-site and interpret the examination remotely.

The use of effervescent agents for the eval-uation of patients with suspected esophagealrupture is controversial. Although efferves-cent granules contain biologically inert com-ponents and the use of these agents has notbeen associated with reported complicationsbeyond the setting of suspected gastrointesti-nal obstruction, the effect of these agents—ifthe solid granules enter the mediastinum—isunknown. However, the granules themselvesdissolve quickly before administration, so itis unlikely that solid granules will enter themediastinum. Nevertheless, the granulesshould be completely dissolved before ad-ministration to avoid the unlikely event ofcomplications related to effervescent granuleadministration. Alternatively, the examina-tion may be performed without effervescentagents followed by effervescent agent ad-ministration if no perforation is seen on theinitial scan.

Conclusion

Helical CT esophagography is a usefultechnique for the evaluation of esophagealperforation in seriously ill patients, may sub-stitute for fluoroscopic esophagography, andcan be performed without direct supervision

by the radiologist. In addition, helical CTesophagography eliminates the need to trans-port patients to the fluoroscopy suite andshortens the time required for definitive diag-nosis of esophageal perforation.

References

1. Swanson JO, Levine MS, Redfern RO, Rubesin SE.Usefulness of high-density barium for detection ofleaks after esophagogastrectomy, total gastrectomy,and total laryngectomy.

AJR

2003;181:415–4202. Backer CL, LoCicero J 3rd, Hartz RS, Donaldson JS,

Shields T. Computed tomography in patients withesophageal perforation.

Chest

1990;98:1078–10803. Levine MS. What is the best oral contrast material to

use for the fluoroscopic diagnosis of esophageal rup-ture?

AJR

1994;162:12434. White CS, Templeton PA, Attar S. Esophageal perfo-

ration: CT findings.

AJR

1993;160:767–7705. Ghanem N, Altehoefer C, Springer O, et al. Radio-

logical findings in Boerhaave’s syndrome.

EmergRadiol

2003;10:8–136. Jaworski A, Fischer R, Lippmann M. Boerhaave’s

syndrome: computed tomographic findings and di-agnostic considerations.

Arch Intern Med

1988;148:223–224

7. Morcos SK. Review article: effects of radiographiccontrast media on the lung.

Br J Radiol

2003;76:290–295

8. Fruchter O, Dragu R. Images in clinical medicine: adeadly examination.

N Engl J Med

2003;348:1016

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