The injured esophagus: imaging spectrum of esophageal emergencies

Esophageal emergencies include a heterogeneous group of conditions that, if not promptly recognized and treated, may progress rapidly to life-threatening complications including mediastinitis, sepsis, and multiorgan failure. The clinical presentation is typically non-specific, including symptoms such as chest pain, dysphagia, odynophagia, and dyspnea, which frequently overlap with more common cardiopulmonary pathologies, making the clinical diagnosis challenging. Imaging therefore occupies a central position in the diagnostic pathway. While fluoroscopic contrast esophagography has historically been the cornerstone examination for evaluating esophageal pathology, multidetector computed tomography (CT) has progressively established itself as the primary modality of choice in the emergency setting, owing to its speed, widespread availability, and unique capacity to simultaneously assess the esophageal lumen, the layered wall structure, and the surrounding mediastinal anatomy. A broad spectrum of pathologic processes may acutely involve the esophagus, ranging from caustic ingestion and spontaneous full-thickness rupture to traumatic injury, foreign body impaction, intramural hematoma, severe infectious esophagitis, iatrogenic perforation, and rare but life-threatening fistulous communications. This pictorial review aims to illustrate the imaging spectrum of esophageal emergencies with particular emphasis on CT findings, highlighting key diagnostic features, potential pitfalls, and the radiologist's role in guiding timely clinical management.