(See also Overview of Esophageal and Swallowing Disorders.)
Endoscopic procedures are the primary cause of esophageal rupture, but spontaneous rupture may occur, typically related to vomiting, retching, or swallowing a large food bolus. The most common site of rupture is the distal esophagus on the left side. Acid and other stomach contents cause a fulminant mediastinitis and shock. Pneumomediastinum is common.
Chest and abdominal x-rays showing mediastinal air, pleural effusion, or mediastinal widening suggest the diagnosis.
Diagnosis of esophageal rupture is confirmed by esophagography with a water-soluble contrast agent, which avoids potential mediastinal irritation from barium. CT of the thorax detects mediastinal air and fluid but does not localize the perforation well. Endoscopy may miss a small perforation.