Esophageal perforation?

CTWSES 2019

Chest pain after vomiting, endoscopy, or a food-bolus impaction; delayed diagnosis worsens morbidity and mortality.

Answer the surgeon

Primary repair vs stent vs conservative management — and whether the leak is contained.

Your answer must state:

Pneumomediastinum and its distribution
Extraluminal oral contrast: site and level of the leak, if oral contrast was given
Periesophageal and mediastinal fluid, fat stranding
Pleural effusion — especially left, the Boerhaave signature (distal posterolateral left wall)
Cervical and subcutaneous emphysema
Contained vs free leak, and the context: post-endoscopy, vomiting, foreign body

Key and direct findings

1.Extraluminal gas centered on the esophagus
Pneumomediastinum concentrated around the esophagus is the leading sign; note where it is densest — it points at the level of the tear.
2.Extraluminal oral contrast
Water-soluble contrast outside the lumen localizes the perforation directly.
3.Visible wall defect
A discontinuity of the esophageal wall, most often distal posterolateral left in Boerhaave.

Supportive signs & checks

1.Left pleural effusion after vomiting
The classic Boerhaave accompaniment, often with atelectasis; a right effusion suggests a mid-esophageal tear.
2.Mediastinitis
Periesophageal fluid, fat stranding, and gas — the reason delay kills; esophageal wall thickening supports the site.
3.CT without oral contrast rarely shows the hole
Indirect signs carry the diagnosis; recommend a water-soluble esophagram or repeat CT with oral contrast to localize the leak.
Pitfall: Pneumomediastinum alone is nonspecific — asthma, barotrauma, and coughing all cause it; correlate with the story.
4.Cervical perforation after endoscopy
Small upper perforations may show only neck emphysema — check the soft tissues of the neck on every post-endoscopy study.

Wet-read snippets

Fill the blanks, then copy into your preliminary report.

Positive

Findings of esophageal perforation: pneumomediastinum centered at the ___ esophagus with ___ (extraluminal contrast / periesophageal fluid) and ___ left pleural effusion. Surgical team notified.

Negative

No pneumomediastinum, periesophageal fluid, or extraluminal contrast — no CT evidence of esophageal perforation.

Sources

WSES guidelines for the management of esophageal emergencies — Chirica M et al. World J Emerg Surg (2019)
CT features of esophageal emergencies — Young CA et al. RadioGraphics (2008)

Content review: Content pending clinical review · 2026-07-15

Educational reference for trained clinicians. Verify every result against the cited original guideline before use. Not a substitute for clinical judgment or medical advice.