Predictive criteria for oesophageal perforation in patients with pneumomediastinum: can invasive diagnostic modalities be avoided?

BACKGROUND

The increased use of CT in emergency departments (ED) has led to a rise in incidental detection of pneumomediastinum (PNM). As this finding can be associated with oesophageal perforation (OP), clinicians face a diagnostic dilemma on whether further invasive investigation (such as endoscopy) is required. This study aimed to identify clinical, biochemical and radiological predictors of OP in patients with PNM, to develop a non-invasive diagnostic approach.

METHODS

A retrospective analysis of adult patients with CT-confirmed PNM was conducted from January 2016 to December 2022 at a tertiary hospital in Queensland, Australia. Data were collected from electronic medical records on demographics, presenting features, vital signs at presentation and 6-24 hours, laboratory results and specific CT findings. Univariable analyses identified candidate predictors of OP, and multivariable logistic regression was used to determine independent predictors.

RESULTS

Among 336 patients with PNM, 22 (6.5%) had confirmed OP. Dysphagia (p<0.001) and vomiting (p=0.002) on presentation were significant univariable predictors of OP. No asymptomatic patients were found to have OP. None of the measured laboratory markers (including white cell count, C-reactive protein and lactate) were predictive of OP. Key CT findings associated with OP were mediastinal free fluid, pleural effusion and oesophageal wall disruption (all p<0.001). Multivariable analysis identified that the combination of mediastinal free fluid plus oesophageal wall disruption was the strongest predictor of OP with a sensitivity of 86.4% and specificity of 98.4%.

CONCLUSION

Clinical features such as dysphagia and vomiting, together with specific CT signs (mediastinal fluid, pleural effusion and oesophageal wall disruption), strongly predict OP in patients with PNM. Patients who are asymptomatic and lack these high-risk features are unlikely to have an OP and can probably be managed conservatively without invasive testing. These findings may help clinicians risk-stratify patients with PNM and avoid unnecessary admissions and invasive procedures.