CT Esophagram (Leak Protocol)

Indications

• Suspected esophageal perforation (Boerhaave syndrome, iatrogenic after endoscopy/dilation, foreign body)
• Post-esophagectomy or post-bariatric anastomotic leak assessment
• Suspected esophageal fistula (esophago-pleural, tracheo-esophageal)

Patient prep

• Confirm the patient can safely swallow; use an iso-osmolar water-soluble agent when aspiration risk exists (hyperosmolar agents like diatrizoate cause pulmonary edema if aspirated)
• Prepare dilute water-soluble oral contrast (2-3% iodinated); a thicker/paste consistency can help coat a suspected upper leak
• Never barium when perforation is suspected (mediastinal barium is inert but obscures reoperation and follow-up)
• IV access if IV contrast will be added for mediastinitis/abscess

Contrast

Technique

• Baseline non-contrast chest first — makes any extraluminal oral contrast on the post-swallow series unequivocal
• Patient drinks on the table and is scanned immediately after (or during, if tolerated) the swallow
• Coverage lower neck through the upper abdomen — include the entire esophagus, stomach and any anastomosis/conduit
• 120 kV; 2-3 mm axial, thin 1-1.25 mm source, coronal/sagittal reformats
• Add IV contrast when mediastinitis, abscess, or empyema is suspected

Series / Sequences

Key points

• CT adds what fluoroscopy can't see: even when no contrast extravasates, periesophageal air, fluid and fat stranding are indirect evidence of perforation — CT esophagram and fluoroscopic esophagram are complementary, and CT is often definitive in sick postoperative patients
• The pre-contrast series is what makes tiny leaks callable — always acquire it
• Choose the oral agent for the airway: iso-osmolar water-soluble contrast if any aspiration risk
• For the fluoroscopic version see the Esophagram (Barium Swallow) protocol

References