A 42-year-old man is evaluated for a 3-month history of burning, substernal chest pain after every meal. The patient has tried several over-the-counter antacids with partial relief. He undergoes upper gastrointestinal endoscopy, which reveals mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter. Multiple biopsies are taken. Four hours after the procedure, the patient develops worsening substernal pain radiating to the back, along with mild shortness of breath. Temperature is 37.1 C (98.9 F), blood pressure is 110/70 mm Hg, pulse is 120/min, and respirations are 34/min. Chest x-ray reveals a small, left pleural effusion that was not present on a chest radiograph taken 2 weeks ago. ECG shows sinus tachycardia but is otherwise unremarkable. Which of the following is the best test to confirm the diagnosis?
Esophageal perforation | |
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This patient has acute chest pain and pleural effusion within hours after endoscopy, most concerning for esophageal perforation (EP). Endoscopy is the most common cause of EP, with adjunctive procedures (eg, biopsy, stricture dilation) further increasing risk. Patients with EP commonly have severe chest pain and/or back pain due to the esophagus's posterior location. Associated clinical findings are due to outflow of esophageal air (eg, pneumomediastinum, pneumothorax) or fluid (eg, pleural effusion) into the surrounding tissues and the resulting inflammatory response (eg, tachycardia, tachypnea).
Esophagography with water-soluble contrast—which can visualize contrast extravasating through the perforation—is the best initial study to confirm EP. Barium contrast is more sensitive but can incite a granulomatous inflammatory response; it is only used when initial esophagography is nondiagnostic. Because EP is a life-threatening condition that can rapidly progress to mediastinitis and septic shock, emergent surgical consultation is indicated. Most perforations require operative debridement and repair.
(Choice A) Upper gastrointestinal endoscopy could likely visualize the esophageal injury in this patient but is not used for initial diagnosis of EP because air insufflation and instrumentation may worsen the injury.
(Choice B) Pancreatitis, which increases serum amylase and/or lipase, can present with severe pain and an exudative pleural effusion (usually left-sided). However, it typically causes epigastric rather than chest pain; although it can develop postprocedurally, it classically follows endoscopic retrograde cholangiopancreatography (due to instrumentation and dye injection involving the pancreatic duct) not upper endoscopy (which does not reach the pancreatic duct).
(Choice C) Elevated amylase in the pleural fluid (due to leaked saliva) could increase suspicion for EP. However, compared to contrast esophagography, pleural fluid analysis has less specificity for the diagnosis (eg, pancreatitis-associated effusion also has elevated amylase) and is unable to localize the tear in preparation for likely surgery.
(Choice D) Severe substernal pain raises concern for a cardiac etiology (eg, myocardial ischemia, pericarditis), which transthoracic echocardiography can help evaluate. However, the absence of concerning ECG findings (eg, ST changes) and this patient's lack of cardiac risk factors make EP a more likely cause of this patient's substernal pain, especially in the setting of recent endoscopy.
Educational objective:
Esophageal perforation is a life-threatening complication of endoscopy. Clinical presentation may include severe chest/back pain, systemic inflammatory response, and pleural effusion from leaked esophageal contents. Contrast esophagography is the best test to confirm the diagnosis.