Overview: With collaboration from CT Surgery, a protocol for CT esophgram exists that obviates the need for traditional fluoroscopy in most patients. CT-esophagram should be the diagnostic modality of choice in working up possible esophageal trauma.
How to Order: CT Chest without, esophagram protocol is listed as an option or can just type 'esophagram' in comments.
When to use vs a fluoro study: deferred that to the ordering provider; practically, you may be best thinking of a CT esophageal protocol as excluding a leak large enough to warrant operating at 2AM and reasonably deferring a fluoro study or scope to the next day.
Important Considerations:
- With a CT esophageal protocol, in practice, you almost never see the actual esophageal wall defect itself unless it is a large leak. Barring an obstruction, the contrast does not stay in the esophagus in a majority of cases, so you end up looking for secondary evidence of leak with contrast appearing in the mediastinum or pleural space, etc.
- It's important that the exam be done without IV contrast. IV contrast can cause enhancement of small vessels or even sometimes the pleural space if there is pleural inflammation that will interfere with identifying small leaks. So if you require IV contrast for some reason, you should not do an esophageal protocol. There is disagreement about this in the literature and some have certainly done protocols with IV contrast, but it may interfere.
- Our current protocol does not include multiple positions. Some publications have done this, but if considering supine, prone or decubitus positioning to be necessary, then you should probably just get an actual fluoro study instead.
- One of the biggest issues from a practical standpoint is on the interpretive side. Many radiologists don't 'trust' the CT exam to exclude leaks with the same sensitivity of a fluoro study, so it can definitely be challenging to not end up with a report that says to do a followup fluoro exam if there is still concern. But in most cases, CT-Esophagram is the diagnostic test of choice.
Bernard 4-30-24
