**6. Perforation**

Although an endoscopy is an important tool for initial evaluation, contraindications are suspected perforation, oral cavity necrosis, and airway injury with compromised respiration. CT scans can safely provide details about esophageal transmural necrosis consisting of esophageal wall blurring, peri-esophageal fat stranding, and no enhancement of esophageal wall after administration of intravenous contrast [24]. Recent studies reported that unnecessary esophagectomy following endoscopic evaluation of patients with Zargar grade 3b could have been avoided if CT had been used [28–30].

Both CT and endoscopy have distinctive advantages. CT is minimally invasive with high sensitivity and specificity [24, 25, 27–30]. Intra-luminal evaluation by endoscopy reveals subtle details of the esophageal mucosa and degrees of damage [31]. The combination of CT and endoscopy is especially useful for examining patients with Zargar 3b injuries [8, 30, 31].
