Pediatric Esophageal Perforation

  • Etiology:
    — Placement of a nasogastric tube
    — Forceful vomiting or retching (Boerhaave syndrome)
    — Blunt trauma against closed glottis
    — AP compression of the chest
  • Imaging CXR: Pneumomediastinum, pneumopericardium, pneumothorax, hydropneumothorax, subcutaneous emphysema, mediastinitis
  • Note: A nasogastric tube that is too straight after placement and that does not gently curve into the stomach should be suspected of not being in the stomach
  • Imaging UpperGI: Contrast outside of esophagus
  • Imaging CT: Contrast outside of esophagus
  • DDX:
  • Complications: Mediastinitis
  • Treatment: Conservative if small, surgical if large
  • Clinical: Can be devastating if not recognized

Radiology Cases of Esophageal Perforation

Radiology Cases of Esophageal Perforation Due to Nasogastric Tube

CXR of esophageal perforation from nasogastric tube placement
CXR AP shows air outlining the heart in the pericardial space, air outlining the thymus in the mediastinum, and air in the bilateral pleural spaces.
AXR of esophageal perforation from nasogastric tube placement
Supine AXR (above) shows increased lucency in the upper abdomen. The cross-table lateral AXR (below) shows air between the anterior abdominal wall and the bowel. The nasogastric tube follows a very straight course and does not curve towards the stomach. Note on both views that the tip of the nasogastric tube does not project over the stomach. US performed subsequently showed the tip of the nasogastric tube was in the retroperitoneum and not in the stomach.
AXR of gastric perforation from nasogastric tube placement
Supine AXR (left) shows a large amount of air within the abdomen and air outlining both sides of bowel wall (Rigler’s sign) in the right lower quadrant. Supine AXR taken later after pulling back of the nasogastric tube out of the stomach shows visualization of the falciform ligament over the spine (American football sign)
AXR of gastric perforation from nasogastric tube placement
Supine AXR (above) shows increased lucency throughout the central abdomen and left lateral decubitus AXR (below) shows air between the abdominal wall and the liver. On both views the tip of the nasogastric tube projects inferior to the gas-filled stomach.
AXR of gastric perforation from nasogastric tube placement
Supine and left lateral decubitus AXR (left) show a nasogastric tube with its tip deep in the pelvis without evidence of free air. Supine AXR taken after pulling the nasogastric tube back into the stomach (above right) shows increased lucency throughout the central abdomen and left lateral decubitus AXR taken at same time (below right) shows air between the abdominal wall and the liver.
Upper GI of esophageal perforation caused by nasogastric tube
AXR AP (above left) shows the nasogastric tube to follow a rather straight course into the abdomen. There is increased lucency in the upper abdomen. Subsequent AXR decubitus (above right) shows free air between the abdominal wall and liver. AP view obtained 9 days later immediately after the injection of water soluble contrast through the nasogastric tube (below left) shows some contrast extravasating out of the esophagus into the mediastinum and some contrast entering the stomach. Lateral view obtained 15 minutes later (below right) shows contrast outlining the left pleural space.

Radiology Cases of Esophageal Perforation Due to Blunt Trauma

CT and UGI of esophageal perforation
Sagittal CT without contrast of the neck (left) shows pneumomediastinum anterior to the spine. Lateral image from an esophagram (right) shows contrast extravasating outside the esophagus at the level of C4.