Management of Suspected Chest Gas After EGD
If chest gas (pneumomediastinum or pneumothorax) is suspected after EGD, immediately obtain a contrast-enhanced CT scan to confirm the diagnosis and assess for esophageal perforation, as this represents a potentially life-threatening complication requiring urgent intervention. 1
Immediate Diagnostic Evaluation
Obtain CT imaging urgently with IV contrast (2 mL/kg at 2-3 mL/s, 18-25 second acquisition, 90-second delay) covering the neck, chest, and abdomen to assess the full extent of injury 1
Add water-soluble oral contrast (Gastrografin, NOT barium) to identify contrast extravasation indicating perforation 1
Key CT findings to identify include:
Consider flexible endoscopy with low-flow CO2 insufflation (NOT air) as an adjunct if CT findings are equivocal, as this combination achieves >90% diagnostic accuracy and alters management in 69% of cases 1
Risk Stratification and Management Algorithm
The decision between non-operative and surgical management depends on three critical factors: hemodynamic stability, perforation containment, and timing 1
Non-Operative Management Criteria (ALL must be present):
- Hemodynamically stable 1
- Early presentation (ideally <24 hours) 1
- Contained esophageal disruption with minimal contamination 1
- No obvious non-contained contrast extravasation 1
- No systemic signs of severe sepsis 1
- Small perforation (<50% esophageal circumference) 1
Non-operative protocol includes: 1
- NPO status
- Broad-spectrum antibiotics
- ICU-level monitoring
- Nasogastric tube placement
- Early nutritional support (enteral or parenteral)
- Serial CT imaging to monitor for clinical deterioration
Immediate Surgical Intervention Required If:
- Hemodynamic instability 1
- Obvious non-contained contrast extravasation on CT 1
- Systemic signs of severe sepsis 1
- Large perforation (>50% of esophageal circumference) 1
- Free fluid or contrast extravasation on CT (associated with 75% failure rate of non-operative management) 2
Surgical Approach When Indicated
- Right thoracotomy for mid-thoracic esophageal access 1
- Primary repair with two-layer closure and buttressing with viable tissue (pedicled omentoplasty) is the treatment of choice 1, 3
- Adequate mediastinal and pleural drainage plus feeding jejunostomy for nutritional support 1
Critical Timing Considerations
Time is the single most important survival predictor: 1
- Mortality <10% if managed within 24 hours 1
- Mortality increases to 30% after 24 hours 1
- Delayed surgical treatment (>24 hours) reduces odds of successful primary repair and increases morbidity 1
Common Pitfalls to Avoid
- Do not rely on clinical examination alone - physical findings are unreliable for early diagnosis, and up to 50% of cases have delayed diagnosis 1
- Do not assume normal mediastinum rules out perforation - CT can miss up to 30% of small perforations 1
- Never perform repeat endoscopy with standard air insufflation - this enlarges the perforation and worsens contamination; always use low-flow CO2 1, 4
- Do not use barium contrast - it impairs subsequent endoscopy and is contraindicated in perforation 1
- Do not delay surgical consultation - even if attempting non-operative management initially, have surgery involved early as 18% of non-operative attempts fail 2
Monitoring for Failed Non-Operative Management
If non-operative management is attempted, patients who fail typically demonstrate: 2
- Free fluid on CT (75% failure rate vs 23% success rate)
- Contrast extravasation (33% failure rate vs 0% success rate)
- Clinical deterioration (fever, tachycardia, worsening pain, sepsis)
Patients who fail non-operative management may have worse outcomes (43% mortality vs 21% for initial operative management), making early surgical consultation critical even when attempting conservative therapy. 2