What diagnostic study is recommended for suspected Boerhaave syndrome?

In the case of suspected Boerhaave syndrome, which is a spontaneous rupture of the esophagus, the preferred diagnostic study is the esophageal study with water-soluble oral contrast. This method is effective because it allows for the visualization of any potential leaks or perforations in the esophageal wall while minimizing the risk of mediastinal or pleural contamination that could occur with barium contrast.

Water-soluble contrast media, such as orally ingested diatrizoate (Gastrografin), is less viscous and can be absorbed if there is an esophageal breach, reducing complications that may arise from using barium. This study can be performed using fluoroscopy, which helps identify any extravasation of contrast into the surrounding mediastinum or pleural spaces, confirming the diagnosis of a perforation.

In contrast, other imaging modalities such as CT scans with contrast may sometimes be used in clinical practice but are not first-line options for diagnosing Boerhaave syndrome because they do not provide the same functional assessment of esophageal leaks. Esophageal manometry assesses motility and would not be effective in confirming a structural rupture. An upper GI series, while it involves barium, does not utilize a water-soluble agent and therefore carries a higher risk