CT oral contrast and contemporary imaging pathways for suspected oesophageal perforation in the emergency department: a retrospective observational study

PURPOSE: To evaluate contemporary computed tomography (CT) imaging pathways for Emergency Department (ED) patients with suspected oesophageal perforation or leak, with a particular focus on oral contrast utilisation, radiologic findings and downstream investigations following the index CT examination. METHODS: We performed a single-centre retrospective observational study of all adult ED patients who underwent CT imaging including the chest for suspected oesophageal perforation or leak between January 2015 and March 2026. Patients were identified through radiology database search. Demographics, clinical indications, oral contrast use, radiologic findings and investigations performed within five days of the index CT were recorded. RESULTS: A total of 107 patients were included, with six (5.6%) confirmed oesophageal perforations. Oral contrast was administered in 62 (57.9%) CT examinations. Overall, 45 patients (42.1%) underwent downstream investigations, with similar rates regardless of oral contrast administration (43.5% vs. 40.0%). However, repeat CT was less frequent following oral contrast-enhanced CT (3.2% vs. 17.8%). Among patients with confirmed perforation, direct signs including oesophageal wall defect and extraluminal contrast leak were common (66.7% each), whilst indirect signs were also frequent present, including pneumomediastinum and pleural effusion (83.3% each). Pneumomediastinum was also frequently observed in patients without perforation. CONCLUSION: Rates of downstream investigation were similar regardless of oral contrast administration, however, repeat CT was less frequently performed following oral contrast-enhanced examinations. These findings suggest that oral contrast may influence subsequent imaging pathways. Prospective studies are warranted to determine whether selective oral contrast administration can improve diagnostic confidence while reducing unnecessary CT examinations.