NBME Surgery Shelf Practice Test

In suspected esophageal perforation, the contrast agent used for imaging should minimize damage if a leak is present. Water-soluble contrast (such as Gastrografin) is preferred because if it extravasates into the mediastinum or pleural space, it causes less inflammatory irritation than barium. This makes it safer to use as the initial radiographic test to detect a leak after endoscopy. If the water-soluble study is inconclusive but clinical suspicion remains high, additional imaging (like CT with oral contrast) can be pursued, but barium is avoided first due to the risk of mediastinitis from leaked material.