Imaging of esophageal perforations: from diagnosis to follow-up

Esophageal perforation is a life-threatening condition with high mortality rate (10-20%) particularly if not treated in short time. The main causes of esophageal perforation in adults are iatrogenic procedures, foreign body ingestion, spontaneous rupture and esophageal cancer. The most important symptoms are atypical chest pain with acute onset, vomit and subcutaneous emphysema, but frequently symptoms are aspecific. The management of esophageal perforations (conservative, endoscopic or surgical approach) depends on timing, location and extension of the lesion, also considering preexisting patient comorbidities. Imaging plays a fundamental role in precocious diagnosis, guiding the correct management, since a tempestive treatment reduces complications and mortality. Actually, there is no concordance regarding the gold standard imaging modality for first evaluation of esophageal perforations: both fluoroscopic esophagography and computed tomography are recommended. Although computed tomography demonstrates a major sensitivity, providing more anatomic details, fluoroscopic esophagography allows to visualize real-time bolus swallowing and extraluminal leakage of contrast media. Our purpose was to show indications and features of the main imaging techniques to help radiologists to correctly manage this potentially fatal condition, that is frequently difficult to recognize clinically.