esophogeal perforation

[sheehan]

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would you use barium or gastrograffin swallow for the diagnosis?
USMLE world says gastrograffin, but I was taught that the water soluble contrast is for a GI perf, and you use barium in the chest.
also from Sabiston -
A contrast esophagram is done using barium for a suspected thoracic perforation and Gastrografin for an abdominal perforation. Barium is inert in the chest but causes peritonitis in the abdomen, whereas aspirated Gastrografin can cause life-threatening pneumonitis.
but from schwartz -
The diagnosis is confirmed with a contrast esophagogram, which will demonstrate extravasation in 90% of patients. The use of a water-soluble medium such as Gastrografin is preferred.

So - any ideas?

 

[smq123]

I was taught to use gastrografin. The thought is that if there IS a perf, then barium could leak out and cause mediastinitis, while gastrografin doesn't.

I know that the risk of gastrografin pneumonitis is bigger, but I think the assumption is that the higher risk is from leaking out through the perf, and less risk from aspirating it.

 

[OveractiveBrain]

For esophageal perforation:

(1) Use gastrographin swallow because it is water soluble, and will not cause mediastinitis if there is a perf. If positive for perforation, go to OR, no more diagnostics need to be done

(2) If gastrographin negative, you must really be sure, so now barium because it is BETTER than gastrographin but causes mediastinitis if positive.

On step 2 you are NOT going to be asked the nuances between abdominal or thoracal perforation, is it above or below the diaphragm? The questions just aren't that complex. You are asking about the esophagus, and for the test, esophagus is mediastinal 100% of the time.

Gastrographin --> Positive Stop
Gastrographin --> Negative, go to Barium

Barium is Better than gastrographin, gastrographin is just safer.