AJR 2004; 182:1177-1179
© American Roentgen Ray Society
Helical CT Esophagography for the Evaluation of Suspected Esophageal Perforation or Rupture
Farhan Fadoo1,
Diego E. Ruiz1,
Samuel K. Dawn1,2,
W. Richard Webb1 and
Michael B. Gotway1,2
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.
Received September 11, 2003;
accepted after revision November 11, 2003.
Address correspondence to M. B. Gotway.
Introduction
Fluoroscopic esophagography performed with water-soluble contrast agents is
the study of choice for suspected esophageal perforation
[1,
2]. However, fluoroscopic
esophagography can be difficult to perform in seriously ill patients and
requires patient transport to the fluoroscopy suite, and false-negative
results may occur [1,
3]. Because esophageal
perforation is one of several diagnostic considerations for patients with
chest pain, many patients with esophageal perforation may first undergo
thoracic CT, requiring fluoroscopic esophagography to be performed as a
separate examination. A method for evaluating patients with chest pain that
provides evaluation for both esophageal perforation and more common causes of
acute chest pain is desirable. We report a CT technique designed to
specifically assess patients for esophageal perforation that may be performed
after routine thoracic helical CT. This technique, which uses low-osmolar IV
contrast material as the oral agent, may obviate fluoroscopic esophagography,
therefore expediting the evaluation of patients presenting with chest
pain.
Materials and Methods
Patient Population
Eleven patients with suspected esophageal perforation underwent a specific
thoracic CT protocol designed to assess for esophageal perforation (helical CT
esophagography). Two patients were examined using thoracic helical CT after
thoracic gunshot wounds; one patient, after blunt trauma; and six patients,
for atraumatic chest pain. One patient refused fluoroscopic esophagography and
underwent helical CT esophagography to exclude anastomotic leak after
esophageal surgery. One patient underwent helical CT esophagography to assess
for gastric-pulmonary fistula after gastric pull-up surgery.
Helical CT Esophagography Technique
All patients were initially scanned with helical CT from the thoracic inlet
to the diaphragm using 5-mm collimation and 3-mm reconstruction increments. On
the initial scan, pneumomediastinum was seen in nine patients. This finding
raised suspicion for esophageal perforation and prompted the performance of
helical CT esophagography. Helical CT esophagography was performed to exclude
postsurgical anastomotic leak for the patient who refused fluoroscopic
esophagography. One patient had necrotizing pneumonia in the right upper lobe,
and helical CT esophagography was performed to exclude gastric-pulmonary
fistula.
All patients received approximately 50 mL of an aqueous solution consisting
of 10% IV iodinated contrast material (Omnipaque 300 [iohexol], Nycomed),
effervescent granules (sodium bicarbonate and tartaric acid), and water either
by rapidly drinking the solution or by injection through a nasogastric tube.
The granules were dissolved in 50 mL of water before consumption; when the
solution was injected via syringe, care was taken not to draw any residual
particulate into the syringe. Thoracic helical CT was then performed using the
exact same parameters as those used for the initial scan without IV contrast
material.
Medical records were reviewed for patients with negative findings on CT
esophagography, no fluoroscopic examination with contrast material, and
neither surgical nor endoscopic confirmation of esophageal perforation
(n = 4).
Results
The study group comprised eight male patients and three female patients.
The average age of patients undergoing helical CT esophagography was 40.1
years (range, 16–84 years).
None of the patients aspirated the oral contrast solution. The additional
CT scans required for CT esophagography added an average of approximately 4
min to the total examination time. Findings from studies were positive for
esophageal perforation in five patients (Figs.
1A,
1B and
2A,
2B) and were negative in six
patients. Fluoroscopic esophagography confirmed esophageal perforation in two
patients with positive CT findings. Four of the five patients with positive CT
findings underwent surgery, and esophageal perforation was confirmed in all;
in the fifth patient, perforation of the intrathoracic stomach
(gastric-pulmonary fistula) was endoscopically confirmed.
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Fig. 1A. —17-year-old girl with gunshot wound to chest. Axial
contrast-enhanced thoracic CT scan obtained after IV contrast injection but
before oral administration of dilute IV contrast medium shows right
periesophageal air collection (arrow).
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Fig. 1B. —17-year-old girl with gunshot wound to chest. Axial thoracic
CT scan obtained after administration of dilute IV contrast medium through
patient's nasogastric tube shows focus of pneumomediastinum (arrow)
has filled with administered oral contrast agent, confirming esophageal
perforation.
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Fig. 2A. —16-year-old boy with gunshot wound to neck and chest. Axial
contrast-enhanced thoracic CT scan obtained after IV contrast injection but
before oral administration of dilute IV contrast medium shows irregular gas
collection (arrow) adjacent to right aspect of cervical
esophagus.
|
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View larger version (130K):
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Fig. 2B. —16-year-old boy with gunshot wound to neck and chest. Axial
thoracic CT scan obtained after administration of dilute IV contrast medium
through patient's nasogastric tube shows irregular gas collection
(arrow) has filled with administered oral contrast agent, confirming
esophageal perforation.
|
|
Two patients who had negative results on helical CT esophagography
underwent endoscopy, which did not reveal esophageal perforation in either
patient.
Medical records were available in three of four patients undergoing CT
esophagography who did not undergo fluoroscopic esophagography, endoscopy, or
surgery. These patients were alive and without clinical evidence of
mediastinitis at hospital discharge at a mean of 11 days (range, 0–30
days) after the CT examination.
Discussion
Esophageal perforation is a life-threatening condition usually occurring as
a complication of upper endoscopy or as a result of thoracic trauma,
esophageal neoplasm, or violent retching. Morbidity and mortality are
dependent on prompt recognition and proper clinical management. Unfortunately,
clinical signs of esophageal perforation are unreliable, and diagnosis
requires imaging or endoscopic evaluation
[4]. However, many patients
with chest pain syndromes are not initially suspected of esophageal rupture
and are first evaluated with thoracic CT. Findings from the initial CT
examination may then raise suspicion of esophageal injury by showing
mediastinal gas or fluid, esophageal thickening, or pleural effusion
[2,
4–6].
Fluoroscopic esophagography with water-soluble contrast material is the
examination of choice for suspected esophageal perforation or rupture
[2]. However, fluoroscopic
esophagography performed with water-soluble contrast agents may produce
false-negative results in 10–38% of patients
[1,
4], and aspiration of
hypertonic oral contrast solution may precipitate pulmonary edema
[7]. Because false-negative
results may occur, a second fluoroscopic esophagogram obtained with
high-density barium is recommended to definitively exclude esophageal
perforation [1]. This second
examination results in additional radiation exposure, additional cost, and
further delays in clinical management. Finally, although the inert nature of
barium generally implies that aspiration of this contrast material is not
associated with deleterious effects
[7], recent evidence suggests
that barium aspiration may produce severe pulmonary inflammation
[8].
Many patients suspected of esophageal perforation are critically ill, and
numerous physical and practical obstacles are inherent in the transfer of such
patients to the fluoroscopy suite. The need for the radiologist to perform
fluoroscopic esophagography may create further delay and cost.
Helical CT offers several advantages over fluoroscopic esophagography
examinations [2,
4–6].
Helical CT esophagography can be performed after an initial thoracic CT scan
is obtained to exclude other causes of chest pain, obviating transport of
seriously ill patients to the fluoroscopy suite. The use of diluted
low-osmolar IV contrast medium ensures that pulmonary edema will not result if
the oral contrast medium is aspirated
[7] and low-osmolar IV contrast
medium that reaches extraluminal soft tissues through a perforated viscus or
ruptured vessel has not been associated with deleterious effects
[7]. Helical CT can readily
detect the small periesophageal air collections that indicate the presence of
esophageal perforation more readily than fluoroscopic esophagography; such air
collections may be the most useful finding for suggesting the presence of
esophageal rupture [4,
5]. Finally, helical CT
esophagography is easy to perform, and CT technicians and nurses can readily
be trained in its use. Once trained, CT technologists can perform helical CT
esophagography without direct radiologist supervision, allowing the
radiologist to attend to other duties or remain off-site and interpret the
examination remotely.
The use of effervescent agents for the evaluation of patients with
suspected esophageal rupture is controversial. Although effervescent granules
contain biologically inert components and the use of these agents has not been
associated with reported complications beyond the setting of suspected
gastrointestinal obstruction, the effect of these agents—if the solid
granules enter the mediastinum—is unknown. However, the granules
themselves dissolve quickly before administration, so it is unlikely that
solid granules will enter the mediastinum. Nevertheless, the granules should
be completely dissolved before administration to avoid the unlikely event of
complications related to effervescent granule administration. Alternatively,
the examination may be performed without effervescent agents followed by
effervescent agent administration if no perforation is seen on the initial
scan.
Conclusion
Helical CT esophagography is a useful technique for the evaluation of
esophageal perforation in seriously ill patients, may substitute for
fluoroscopic esophagography, and can be performed without direct supervision
by the radiologist. In addition, helical CT esophagography eliminates the need
to transport patients to the fluoroscopy suite and shortens the time required
for definitive diagnosis of esophageal perforation.
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Introduction
Materials and Methods
