What is the next step in management for a patient with severe chest pain and crepitus after a diagnostic upper endoscopy?

Immediate Management: CT Scan with Oral Contrast

The next step in management is (c) Gastrografin swallow, though CT scan with oral contrast is superior and should be performed instead if available. This patient has severe chest pain and crepitus (subcutaneous emphysema) after upper endoscopy, which are classic signs of esophageal perforation—a life-threatening medical emergency requiring immediate diagnostic confirmation 1.

Clinical Reasoning

Why This is Esophageal Perforation Until Proven Otherwise

• Severe chest pain after endoscopy combined with neck crepitus is pathognomonic for perforation 1
• The crepitus indicates subcutaneous emphysema from air escaping through a perforation into the mediastinum and tracking into the neck tissues 2
• Perforation should be suspected when patients develop pain, breathlessness, fever, or tachycardia after esophageal procedures 1
• This is a medical emergency requiring assessment by both an experienced physician and experienced surgeon 1

Optimal Diagnostic Approach

CT scan with oral contrast is the gold standard and should be performed immediately 1:

• CT is superior to conventional contrast studies (Gastrografin swallow) as it is more sensitive and can detect small perforations that water-soluble contrast studies may miss 1
• CT can identify additional complications including pneumothorax, pneumomediastinum, pleural effusions, and pneumoperitoneum 1
• Chest X-ray alone is insufficient—it may show pneumomediastinum, pneumothorax, air under the diaphragm, or pleural effusion, but normal appearances do not exclude perforation 1

If CT is unavailable, water-soluble contrast swallow (Gastrografin) is acceptable but less sensitive 1:

• This is the traditional approach and remains valid when CT is not immediately accessible 1
• Water-soluble contrast is preferred over barium to avoid mediastinal contamination if perforation is confirmed 1

Why the Other Options Are Wrong

(a) Repeated Upper Endoscopy

• Only indicated if the patient becomes symptomatic while still in the procedure room to assess for perforation and potentially place an immediate endoscopic stent 1
• This patient is already symptomatic with clear signs of perforation, so imaging confirmation is the priority 1
• Endoscopic re-inspection may be considered after imaging confirms perforation to facilitate immediate stent placement 1

(b) Immediate Endotracheal Intubation

• Not indicated unless there is airway compromise or the patient requires airway protection for large-volume bleeding 1
• While subcutaneous emphysema can progress, prophylactic intubation is not the immediate next step 3, 4
• Intubation may be needed later if respiratory distress develops, but diagnostic confirmation of perforation takes priority 3, 4

(d) Aspirin and Sublingual Nitrite

• This treats cardiac chest pain, not esophageal perforation 5, 6
• Administering these medications would dangerously delay diagnosis and treatment of a surgical emergency 1
• The presence of crepitus makes this a structural problem, not an ischemic cardiac event 2

(e) ICU Admission with Narcotics and Observation

• Conservative management alone is inappropriate without first confirming the diagnosis and extent of perforation 1
• While some perforations may be managed conservatively, this decision requires imaging confirmation and multidisciplinary assessment by experienced physicians and surgeons 1
• Narcotics alone would mask symptoms and delay recognition of clinical deterioration 1

Critical Management Pitfalls

Do not delay imaging to "observe" the patient—esophageal perforation has significant mortality risk (0.5-2.3% for benign strictures, higher for complex cases), and early diagnosis is crucial 1:

• Perforation can lead to mediastinitis, sepsis, and death if not promptly identified and treated 1, 2
• The patient should be kept NPO (nothing by mouth) immediately 1
• Broad-spectrum antibiotics should be initiated once perforation is confirmed 1

After imaging confirms perforation, management options include 1:

• Surgical repair (traditional approach for large perforations)
• Endoscopic stent placement (increasingly used for contained perforations)
• Conservative management with NPO status, antibiotics, and drainage (only for very small, contained perforations in stable patients)

The decision requires urgent consultation with experienced gastroenterology and surgical teams 1.