From the Guidelines
In this case, oesophagoscopy (Option A) would be the appropriate next step. The clinical picture suggests an esophageal perforation rather than a gastric perforation. The patient has trauma to the middle chest with left-sided emphysema, and a left-sided chest tube was inserted without improvement. This constellation of findings strongly suggests an esophageal injury with leakage of air and possibly gastric contents into the mediastinum and pleural space. Esophageal perforation can cause subcutaneous emphysema and pleural effusion that won't resolve with chest tube drainage alone if the source of the leak isn't addressed.
- Key considerations include:
- The initial diagnosis of gastric perforation may have been incorrect or incomplete, given the lack of improvement with chest tube insertion.
- The presence of left-sided emphysema and the failure of chest tube drainage to improve the patient's condition point towards an esophageal injury.
- Oesophagoscopy would allow direct visualization of the esophageal mucosa to identify the site of perforation, as suggested by the clinical practice update on endoscopic management of perforations in the gastrointestinal tract 1.
- The study by 1 emphasizes the importance of endoscopic closure of gastric perforations but does not directly address esophageal perforations; however, it highlights the role of endoscopy in managing gastrointestinal tract perforations, supporting the use of oesophagoscopy in this scenario to assess and potentially manage an esophageal perforation.
- Bronchoscopy would be more appropriate if there were concerns about tracheobronchial injury, but the clinical picture (particularly the diagnosis of gastric perforation and lack of improvement with chest tube) points more toward an esophageal injury that requires direct esophageal evaluation and likely surgical repair once identified.
From the Research
Diagnostic Approach
Given the scenario of trauma in the middle chest, left-sided emphysema, diagnosed as gastric perforation, with a left-sided chest tube inserted but showing no improvement, the focus should be on accurately diagnosing the cause of the lack of improvement. The initial diagnosis of gastric perforation may need to be revisited, considering other potential injuries such as esophageal trauma.
Consideration of Esophageal Injury
- Esophageal injuries can be difficult to diagnose and may not always be immediately apparent [(2,3,4)].
- The use of flexible esophagoscopy (FE) has been shown to be an accurate diagnostic tool for detecting esophageal injuries, including lacerations and contusions 2.
- FE demonstrated high sensitivity, specificity, and accuracy in diagnosing esophageal injuries, making it a valuable tool in cases where esophageal trauma is suspected 2.
Relevance to the Scenario
- Given the lack of improvement with the current treatment for gastric perforation, it is essential to consider other potential diagnoses, such as esophageal injury.
- Performing an oesophagoscopy could help diagnose or rule out esophageal trauma, which might be contributing to the patient's condition [(2,3,4)].
- Bronchoscopy, while useful for diagnosing respiratory issues, may not directly address the potential esophageal injury suggested by the lack of improvement with gastric perforation treatment.
Decision
Based on the provided evidence, A. Oesophagoscopy would be the more appropriate next step in diagnosing the cause of the lack of improvement in this patient's condition, given its relevance to potentially identifying esophageal injuries [(2,3,4)].