From the Guidelines
The best test to evaluate the esophagus in a patient with pneumomediastinum is a contrast-enhanced computed tomography (CT) scan, specifically a CT esophagography, due to its high sensitivity and specificity in detecting esophageal perforation or injury [ 1, 1].
Key Points
- A CT scan can help identify any esophageal perforation or leak, which is a potential cause of pneumomediastinum [ 1, 1].
- CT esophagography has high sensitivity (92-100%) and specificity rates in detecting upper digestive tract perforation [ 1, 1].
- A contrast-enhanced CT scan can also provide important information regarding the trajectory of the penetrating agent, associated injuries, and indirect signs of esophageal perforation, such as paraesophageal collections, free air, and pleural effusions [ 1, 1].
- While an esophagram, specifically a contrast esophagram using water-soluble contrast medium such as gastrografin, may also be useful, CT esophagography is generally preferred due to its higher sensitivity and ability to provide more comprehensive information [ 1, 1].
Additional Considerations
- Endoscopy may also be considered, but it should be performed with caution and only after a CT scan has been done to rule out a perforation [ 1, 1].
- The choice of test may depend on the patient's stability and ability to undergo the procedure, as well as the availability of resources and expertise [ 1, 1].
From the FDA Drug Label
Oral administration is used for radiographic evaluation of the esophagus, stomach and proximal small intestine. The best test to evaluate the esophagus in a patient with pneumomediastinum is a radiographic evaluation using an oral contrast agent such as Gastrografin 2.
- The oral administration of contrast media can be used to evaluate the esophagus.
- Gastrografin is a suitable contrast agent for this purpose.
From the Research
Diagnostic Tests for Esophageal Evaluation
The best test to evaluate the esophagus in a patient with pneumomediastinum is a topic of discussion among various studies.
- CT esophagography is considered a sensitive test for diagnosing esophageal perforation, with a sensitivity of 89% and 89% for expert radiologists, respectively, and 79% and 82% for general radiologists 3.
- Fluoroscopic esophagography is often used as a reference standard, but its sensitivity is lower, at 46% 3.
- A study suggests that CT with oral contrast material should be considered the initial imaging examination and can obviate fluoroscopic esophagography in ED patients with suspected esophageal perforation 4.
- Another study found that thoracic computed tomography (TCT) without oral contrast has 100% sensitivity and negative predictive value for excluding esophageal perforation, and fluoroscopic esophagography may be omitted in patients with no evidence of mediastinal collection, pneumomediastinum, or esophageal wall defect on TCT 5.
Specific Patient Populations
- In pediatric patients with spontaneous pneumomediastinum, esophagrams are not indicated, as abnormalities are rarely demonstrated, and patients are exposed to radiation doses during the procedure 6.
- A study found that a single-contrast water-soluble esophogram alone is sensitive in the diagnosis of esophageal injury or leak, with a 100% sensitivity and negative predictive value, and a follow-up barium esophogram only increases the study time and radiation dose to the patient 7.
Imaging Findings
- The most common CT/CTE findings in esophageal perforation are esophageal wall thickening, pneumomediastinum, and mediastinal stranding 3.
- CT findings such as pneumomediastinum, pleural effusion, pneumothorax, unexplained mediastinal fluid or stranding, esophageal wall air or frank esophageal wall disruption, or extraluminal oral contrast material are documented in patients with suspected esophageal perforation 4.