What is the next diagnostic test for a patient with severe substernal pain and left pleural effusion 8 hours after esophagogastroduodenoscopy (EGD)?

Diagnostic Approach for Post-EGD Substernal Pain with Left Pleural Effusion

A water-soluble esophagogram (option d) is the next appropriate test for a patient with severe substernal pain and left pleural effusion 8 hours after EGD, as it can rapidly diagnose esophageal perforation while minimizing complications from contrast extravasation. 1

Clinical Scenario Analysis

The clinical presentation strongly suggests esophageal perforation as a complication of the recent EGD:

• Severe substernal pain developing 8 hours post-procedure
• Left pleural effusion on chest x-ray
• Recent instrumentation of the esophagus (EGD)

This combination of symptoms and findings represents a potentially life-threatening emergency that requires immediate diagnosis and management.

Diagnostic Test Selection

Water-soluble esophagogram (CORRECT CHOICE)

• Provides direct visualization of contrast extravasation at perforation site
• Allows assessment of location and contained vs. uncontained nature of perforation
• Minimizes risk of mediastinal contamination compared to barium studies
• Recommended as first-line imaging by the World Journal of Emergency Surgery guidelines 1

Why not the other options?

1. Repeated EGD (option a)

   • Contraindicated in suspected perforation
   • Risk of enlarging perforation size and worsening contamination
   • Could aggravate mediastinal contamination 1
   • Should be limited to cases with doubtful CT findings after initial imaging

2. Celiotomy (option b)

   • Surgical exploration without definitive diagnosis is inappropriate
   • Diagnostic imaging should precede surgical intervention
   • Would not address thoracic/mediastinal pathology

3. CT scan of chest (option c)

   • While CT has high sensitivity (92-100%) for detecting perforation 1
   • Water-soluble contrast studies provide better functional assessment
   • CT esophagography would be acceptable alternative but standard water-soluble esophagogram is preferred first 2

4. Thoracotomy (option e)

   • Highly invasive surgical procedure
   • Should not be performed without definitive diagnosis
   • Reserved for treatment after diagnosis is confirmed

Clinical Implications

Esophageal perforation carries 10-20% mortality, with delay in treatment being the most important predictor of poor outcomes 1. The water-soluble esophagogram:

• Provides rapid diagnosis
• Guides subsequent management decisions
• Helps determine if perforation is contained or uncontained
• Minimizes risk of contrast-related complications

Important Considerations

• If the water-soluble contrast study is negative but clinical suspicion remains high, some evidence suggests a follow-up barium study may detect leaks missed by water-soluble contrast 3
• CT with oral contrast could be considered as an alternative with similar sensitivity but may miss small perforations 4
• Time is critical - mortality increases significantly with delays beyond 24 hours

In summary, a water-soluble esophagogram is the most appropriate next step for this patient with suspected esophageal perforation following EGD, as it provides rapid diagnosis while minimizing potential complications from contrast extravasation.