46F sent from GI after undergoing endoscopy with biopsy for an esophageal mass, the patient had acute onset of substernal chest pest pain and was transferred to the ED for evaluation. EKG is normal. Chest x-ray is pending.
The patient has stable vitals, maintaining her airway. On exam, the patient is uncomfortable, but otherwise no acute findings noted.
What additional imaging does she need?
CT chest with oral barium contrast to evaluate for esophageal perforation.
Barium contrast is known to cause peritonitis in the abdomen, thus it is avoided when there is concern for bowel perforation. In animal models, aspirated barium lead to non-life threatening granulomas. In contrast, iodinated contrast (i.e. Gastrografin, Isovue) is hyperosmolar and causes pulmonary edema when in the pleural space or aspirated based on several case reports.
concern for esophageal perforation – use Barium
concern for bowel perforation – use Iodinated contrast
note: iso-osmolar iodinated contrast can be considered in esophageal perforation due to reduced risk of pulmonary edema
references: British Journal of Radiology (2003) 76, 290-295doi: 10.1259/bjr/54892465,