Management of Contrast Extravasation Near the Upper Esophagus
For a patient with contrast extravasation surrounding the mid trachea at the level of the upper esophagus, a CT contrast study should be performed to assess the degree of extravasation, followed by multidisciplinary team management including a gastrointestinal surgeon, gastroenterologist, radiologist, and dietitian. 1
Diagnostic Assessment
Immediate Evaluation
- Perform contrast-enhanced CT and CT esophagography to accurately determine:
- Location and extent of extravasation
- Whether extravasation is contained (within 2-3 cm of lumen) or extensive
- Presence of associated injuries or complications 1
Additional Diagnostic Steps
- Consider flexible endoscopy as an adjunct to CT in cases with equivocal findings 1
- Look for clinical signs of perforation:
- Persistent chest pain
- Fever
- Breathlessness
- Tachycardia 1
Management Algorithm Based on Severity
1. Limited Extravasation (<3 cm from lumen)
- Conservative management is recommended 1:
- Nil per os (NPO) status
- Broad-spectrum antibiotic coverage
- Nasogastric tube placement
- Intravenous fluids
- Early nutritional support via enteral feeding or total parenteral nutrition
- Drainage of any cavities via nasal tube with daily reassessment
2. Extensive Extravasation or Signs of Sepsis
- Immediate surgical intervention is indicated for patients with 1:
- Hemodynamic instability
- Obvious non-contained extravasation
- Systemic signs of severe sepsis
3. Drainage Procedures for Contained Extravasation
- For limited cavities or extravasation, the cavity should be drained by an endoscopically placed drain, with or without suction 1
- Consider endoscopic vacuum therapy, which has shown good results in anastomotic leaks and perforations 1
Important Clinical Considerations
Timing of Intervention
- Surgery should be undertaken as soon as possible if indicated
- Delayed surgical management (>24 hours) of esophageal perforation results in increased morbidity and mortality rates 1
Monitoring Requirements
- Intensive care unit monitoring is essential for non-operative management 1
- Monitor patients for at least 2 hours in recovery and provide clear written instructions 1
- Ensure patients have contact information for the on-call team should they experience chest pain, breathlessness, or become unwell 1
Potential Complications to Monitor
- Mediastinal contamination
- Pleural effusions
- Sepsis
- Esophageal stricture formation
Follow-up Care
- Daily reassessment of any cavities in the initial stages 1
- Consider stent placement if tears are slow to heal or if there is a significant extramural cavity 1
- Endoscopic reassessment may be necessary to evaluate healing
Pitfalls and Caveats
- Do not delay management of esophageal perforation as this significantly increases morbidity and mortality
- Avoid oral administration of fluids in patients with suspected perforation
- Regular chest X-rays may not exclude perforation; CT with oral contrast is more sensitive 1
- Carbon dioxide insufflation instead of air should be used during endoscopy to minimize luminal distension and post-procedural pain 1
Remember that esophageal perforation is a medical emergency requiring prompt assessment by experienced physicians and surgeons to formulate an appropriate management plan.