A 42-year-old man swallows a piece of meat lodged in the lower esophagus; the foreign body is removed endoscopically. That evening he develops fever. What is the most appropriate diagnostic study to evaluate for a complication?

A 42-year-old man swallows a piece of meat lodged in the lower esophagus; the foreign body is removed endoscopically. That evening he develops fever. What is the most appropriate diagnostic study to evaluate for a complication?

• A. Esophagoscopy with biopsy
• B. Water-soluble contrast upper GI study
• C. Barium swallow
• D. CT scan of chest

Answer: (B)

When fever appears after endoscopic removal of a foreign body from the esophagus, the concern is an esophageal perforation with potential mediastinal infection. The best initial test to evaluate for a leak is a water-soluble contrast upper GI study. This study will reveal extravasation of the contrast from the esophageal lumen into the mediastinum or surrounding spaces if a perforation is present, giving a direct and safe assessment of the integrity of the esophageal wall. Water-soluble contrast is preferred over barium in this setting because, if a perforation exists, it causes less local irritation and inflammatory reaction in the mediastinum. If the water-soluble study is negative but clinical suspicion remains high, a subsequent barium study can be considered to increase sensitivity, or a CT with contrast can help assess for associated mediastinal infection or collections. Esophagoscopy with biopsy is avoided when perforation is suspected because instrumentation can worsen the perforation and does not provide a reliable leak assessment.

When fever appears after endoscopic removal of a foreign body from the esophagus, the concern is an esophageal perforation with potential mediastinal infection. The best initial test to evaluate for a leak is a water-soluble contrast upper GI study. This study will reveal extravasation of the contrast from the esophageal lumen into the mediastinum or surrounding spaces if a perforation is present, giving a direct and safe assessment of the integrity of the esophageal wall.

Water-soluble contrast is preferred over barium in this setting because, if a perforation exists, it causes less local irritation and inflammatory reaction in the mediastinum. If the water-soluble study is negative but clinical suspicion remains high, a subsequent barium study can be considered to increase sensitivity, or a CT with contrast can help assess for associated mediastinal infection or collections. Esophagoscopy with biopsy is avoided when perforation is suspected because instrumentation can worsen the perforation and does not provide a reliable leak assessment.