CT for Detection, Fluoroscopy for Confirmation: A Meta-Analysis of Imaging in Suspected Esophageal Perforation

BackgroundEsophageal perforation is a time-critical emergency in which delayed diagnosis is associated with substantial morbidity and mortality. Fluoroscopic esophagography (FE) and computed tomography esophagram (CTE) are commonly used, but their optimal roles in the acute diagnostic pathway remain uncertain. We performed a systematic review and meta-analysis comparing the diagnostic performance of FE and CTE in adults with suspected esophageal perforation and clarifying their complementary utility.Study DesignPubMed, Embase, and Cochrane Library were searched from inception to October 26, 2025, for observational studies evaluating both FE and CTE in adults with suspected esophageal perforation and providing data for 2 × 2 contingency tables. Pooled diagnostic estimates were calculated using univariate and bivariate random-effects models. Direct comparisons were performed using Z tests on transformed summary estimates.ResultsFour retrospective studies including 439 patients met inclusion criteria; 69 patients (15.6%) had confirmed perforation. FE showed pooled sensitivity of 69.2% (95% CI, 48.9-84.0) and specificity of 98.4% (95% CI, 96.3-99.4). CTE showed higher sensitivity (81.8%; 95% CI, 38.5-97.0) but lower specificity (86.7%; 95% CI, 67.3-95.4). Sensitivity and specificity did not differ significantly between modalities. However, FE had significantly higher PPV, PLR, and AUC than CTE, indicating stronger rule-in and overall discriminative performance.ConclusionsCTE and FE should be considered complementary tests. CTE is well suited for initial evaluation because of its sensitivity and broader anatomic assessment, whereas FE provides stronger confirmatory value, supporting a sequential strategy of initial CTE followed by selective FE.