To the Editor:
I enjoyed reading “The Injured Esophagus” in the December 2010 issue of the Texas Heart Institute Journal. 1 I am a diagnostic and interventional radiologist, and on the matter of imaging, I agree with some of the author's comments but disagree with others. Contrary to the statement that a chest computed tomogram (CT) rarely adds more than what is seen on chest radiography, a chest CT often adds a tremendous amount of information in the workup of patients with chest pain or suspected esophageal injury. Not only are unexpected findings often made, but the cause of the pain may be nonesophageal and well demonstrated by CT. Furthermore, there are complications of esophageal perforation that must be evaluated by CT to direct appropriate management. Although fast and useful for major findings, chest radiographs are relatively insensitive for a host of conditions.
While emphasizing that the sensitivity and specificity of CT are impressive, I do agree that an esophagram certainly should be part of the workup. I am aware of the importance in knowing both the level and the side of the perforation, and an esophagram can readily evaluate both. I no longer use Gastrografin® because it can cause a nasty pneumonitis if it is aspirated, but I don't agree that barium sulfate is always essential. I will often orally administer an iodinated contrast agent, such as iohexol, to these patients. Then if the results are negative, I will use barium. Iohexol is typically used intravenously for CT scans, pyelograms, and so on; it is very well tolerated whether given intrathecally, intravascularly, intracavitarily, or orally. I am not aware that water-soluble contrast medium has a high false-positive rate; rather, the false-negative rate can be high. If the initial swallow with iohexol is positive, then I have my answer. However, if the initial swallow is negative, I then use barium to improve accuracy. Barium-induced mediastinitis/fibrosis is a real entity, and that is why I avoid barium initially.
Ronald B. Workman, Jr., MD
Radiology of Huntsville, PC, Huntsville, Alabama
Footnotes
Letters to the Editor should be no longer than 2 double-spaced typewritten pages and should generally contain no more than 6 references. They should be signed, with the expectation that the letters will be published if appropriate. The right to edit all correspondence in accordance with Journal style is reserved by the editors.
References
- 1.Mattox KL. The injured esophagus. Tex Heart Inst J 2010;37 (6):683–4. [PMC free article] [PubMed]