Imaging recommendation · Abdomen · Pelvis

Suspected esophageal perforation (Boerhaave, iatrogenic)

Q: What's the alternative imaging for suspected esophageal perforation (boerhaave, iatrogenic) when localizing the leak?

XR — Water-soluble esophagram (gastrografin), then dilute barium if negative (oral contrast).

Recommended: CT Chest / Abdomen with IV + water-soluble esophagram is the preferred imaging study for suspected esophageal perforation (boerhaave, iatrogenic). Mediastinal air, pleural effusion.

Recommended study

CT Chest / Abdomen with IV + water-soluble esophagram

CT IV contrast Preferred Abdomen · Pelvis Emergency Reviewed 2026-05

Mediastinal air, pleural effusion. Avoid barium when perforation is suspected.

If the default doesn't apply

Localizing the leak

XR Water-soluble esophagram (gastrografin), then dilute barium if negative Oral contrast

Atypical or contained perforation

Endoscopy No contrast

Watch-outs

Mediastinitis

Mortality > 20% if delayed > 24 h; broad-spectrum antibiotics and urgent surgical consult.

Iatrogenic vs spontaneous

Most are iatrogenic (post-EGD, dilation, intubation); Boerhaave is rare but classic.

Pearls

Mackler triad (vomiting + chest pain + subcutaneous emphysema) — uncommon but pathognomonic for Boerhaave.
Distal-third left lateral wall is the typical Boerhaave location.
Endoscopic clip, stent, or surgery depending on size, location, and patient stability.