Water-soluble Contrast for the Diagnosis of Esophageal Perforation: A Note of Caution

Abstract

Purpose: Esophageal perforation requires early diagnosis and carries a high penalty for delayed treatments. Even with a rapid diagnosis, esophageal perforation holds an overall mortality of nearly 20%. When treatment is delayed over 24 hours mortality doubles. Water-soluble contrast agents, such as gastrografin, are supported as first line screening of suspected perforation due to their rapid absorption. If perforation is not initially detected and clinical suspicion remains high, a serial barium contrast esophagography is recommended to follow. We present a fatal case of esophageal perforation complicated by gross thoracic contamination of water-soluble contrast. A 57-year-old man was transferred with coffee ground emesis. Prior to transfer, he underwent an upper endoscopy showing a potential disruption of the esophagus. For further evaluation a swallow study with a non-ionic water-soluble contrast was performed. A subsequent unenhanced CT scan of the thorax demonstrated a well-defined defect along the anterior wall of the esophagus with a large accumulation of contrast in this area of the thorax. Upon transfer, emergent upper endoscopy revealed a perforation of the esophagus, 36 cm distally to 34 cm proximally with a large adjacent area of ulceration. After appreciation of gross thoracic contamination, the endoscope was advanced through the perforation into the right thorax with the intent of using a 6-mm port scope to lavage the region and remove the liquid and solid debris. The entire thorax was covered with a thick, gelatinous glue-like covering. Copious lavage and suctioning of the exudative debris and tissue was performed using an estimated 700 mL of normal saline; however, the glue-like contrast precluded meaningful results. After decompression, a 22 mm x 12 cm fully covered esophageal stent (Alimaxx, Merit Medical Co, South Jordan, UT) was successfully deployed. The family declined further procedures and opted for a palliative approach. The patient expired 1 week later. Endoscopic assessment and immediate treatment (temporary stenting) is playing an increasing role in esophageal perforation. When extraluminal contamination is identified, it has been our practice to use low-pressure washout and decompression prior to stenting or direct surgical management in cases where endoscopic treatment is likely to be insufficient. Here we describe a case of a thoracic cavity covered in contrast media that stifled efforts to provide an effective washout. This reinforces the movement towards upper endoscopy as first-line evaluation. This allows for direct visualization of the esophageal defect and potential avoidance of contrast agents given the ramifications of gross thoracic contamination.