LAUSR

I read with interest the overall well-written review of the approach to the diagnosis and management of oesophageal injuries from Petrone et al. [1]. The one area that concerned me was the somewhat dismissive and cursory review of the role of contrast oesophagogram in these patients. They also appear to still advocate for the use of Gastrograffin as the agent of initial choice for the performance of the swallow examination. There has been a reasonably large series published, from South Africa that showed 100% sensitivity, over 99% specificity and a negative predictive ratio of over 99% demonstrated, when using an iso-oncotic contrast medium, such as Omnipaque (Iohexol, GE Healthcare, UK) or Ultravist (Iopropamide, Bayer, Germany), both of which are iso-oncotic water-soluble contrast agents similar to Hexabrix (Mallinckrodt, Hazelwood, Missouri, USA) used in the original studies [2]. The reason for using iso-oncotic solutions is that the use of Gastrograffin, while not associated with mediastinal fibrosis as Petrone and colleagues mention, is unfortunately associated with severe aspiration induced lung injury (chemical pneumonitis) in cases where there is either overflow aspiration or a trauma trachea-oesophageal fistula. Numerous case reports have confirmed the high risk when using Gastrograffin [3]. For this reason Gastrograffin is no longer recommended as the first-line contrast agent by most radiology services in South Africa. This practical point is relevant to the diagnostic algorithms for facilities in countries where high-quality CT scan is less available and fluoroscopy is still the mainstay of oesophageal evaluation. With modern fluoroscopy machines and a co-operative patient