CT features of esophageal emergencies

Guide to extraluminal fish bone retrieval with serial computed tomography scans: a case series

BACKGROUND

Fish bone ingestion is commonly encountered in emergency department. It poses a diagnostic and therapeutic challenge particularly when it migrates extraluminally, necessitating a comprehensive and multidisciplinary approach for successful management.

CASE PRESENTATION

Here we reported four cases of extraluminal fish bone. The first patient was a 68-year-old Chinese man who had odynophagia shortly after a meal involving fish. The second was a 50-year-old Iban man who reported a sharp throat pain after consuming fish 1 day prior. The third patient was a 55-year-old Malay woman who developed throat pain and odynophagia after consuming fish 1 day earlier. The fourth patient, a 70 year-old Iban man, presented late with odynophagia, neck pain, swelling, and fever 1 week after fish bone ingestion. These unintentional fish bone ingestions faced challenges and required repeat computed tomography scans using multiplanar reconstruction in guiding the surgical removal of the fish bone.

CONCLUSION

We underscore the significance of multiplanar reconstruction in pinpointing the fish bone's location, demonstrating the migratory route, and devising an accurate surgical plan.

The role of radiology in diagnosing gastrointestinal tract perforation

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

CT esophagogram in the emergency setting: typical findings and suggested workflow

PURPOSE

Esophageal perforation (EP) can be a diagnostic challenge. Computed tomography (CT) and CT esophagography (CTE) are often used to rule out EP in the emergency setting with promising diagnostic performance, but the standard of care remains fluoroscopic esophagography (FE). We assess the diagnostic performance of CT and CTE when interpreted by expert and generalist radiologists and created an imaging workflow guide.

METHODS

Retrospective study of patients presenting with suspected EP. Two expert radiologists independently reviewed blinded CT/CTE studies, recorded CT findings, and assigned an esophageal injury grade. We also collected initial (general radiologist) CT findings and interpretation and FE diagnoses. We assessed inter-reader reliability and diagnostic performance.

RESULTS

EP was diagnosed in 46/139 (33%) encounters. The most common CT/CTE findings in EP were esophageal wall thickening (46/46, 100%), pneumomediastinum (42/46, 91%), and mediastinal stranding (39/46, 85%). CT and CTE sensitivity for detecting EP was 89% and 89% for expert radiologists, respectively, and 79% and 82% for general radiologists, compared with 46% for FE. Inter-reader agreement for detecting EP by CT and CTE was kappa 0.35 and 0.42 (both p < .001) between expert and generalist radiologists. We present radiographic images for key CT/CTE findings and a suggested workflow for the evaluation of possible EP.

CONCLUSION

CT and CTE are more sensitive than FE for EP in the emergency setting. Due to the rarity of EP and current wide variability in imaging interpretation, an imaging workflow and injury grading system based on esophageal and mediastinal CT findings are offered to help guide management.

Early Diagnosis and Surgical Management of Boerhaave Syndrome: A Case Report

Boerhaave syndrome is a rare condition of spontaneous esophageal perforation after multiple episodes of forceful emesis. Due to its high morbidity and mortality rates, early diagnosis and treatment are key prognostic factors. Herein, we present a case of Boerhaave syndrome, which was initially misinterpreted as a coronary event due to similar confusing symptoms. However, a diagnosis was made without delay and confirmed with a chest computed tomography (CT) scan, which revealed pneumomediastinum. The patient was treated surgically by primarily repairing the rupture with an omentum patch reinforcement, draining the mediastinum and both pleural cavities, and creating a feeding jejunostomy. After a long stay in the ICU and the Surgical Department, the patient was discharged in good clinical condition with normal oral feeding.

Point-of-Care Ultrasonography Helped to Rapidly Detect Pneumomediastinum in a Vomiting Female

Vomiting-induced pneumomediastinum is a rare presentation and can be a result of alveolar rupture (Mackler effect) or Boerhaave syndrome. Patients diagnosed with Boerhaave syndrome may present with the classic Mackler triad of vomiting, chest pain, and subcutaneous emphysema. However, there exists a large overlap of symptoms accompanying Boerhaave syndrome and the Macklin effect, including retrosternal chest pain, neck discomfort, cough, sore throat, dysphagia, dysphonia, and dyspnea. Boerhaave syndrome is a dangerous condition. Delayed diagnosis of Boerhaave syndrome may worsen sepsis and cause mortality. Therefore, early diagnosis and timely management are important to prevent further complications. Here, we present a case of vomiting-induced pneumomediastinum, which supports the use of bedside ultrasonography to aid in the diagnosis and rapid differentiation of etiology of pneumomediastinum.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

Thyroid abscess due to ingested fish bone, endoscopic, and surgical approach: a case presentation

Introduction

Thyroid abscesses are a rare septic complication as the thyroid is innately resistant to infection.

Case presentation

Here, we present a case of a 49-year-old female with history of accidental ingestion of a fish bone, subsequent perforation of the esophagus, and thyroid abscess formation.

Management approach consisted of imaging of the gland followed by upper gastrointestinal endoscopy and surgical thyroidotomy with fish bone extraction.

Conclusion

In this case presentation, we highlight the pathophysiology behind thyroid abscess along with review of offered lines of management of this disease from imaging and procedures of diagnosis to treatment approach of source control by both surgical and conservative approach.

3D modeling and comparative analysis of the double arcus aorta case

We analyzed the double arch of a 51-year-old male patient who applied to the outpatient clinic with chest pain and shortness of breath and compared this rare case with the studies in the literature. Double aortic arch (DAA) is defined as a type of vascular ring malformation. The incidence of congenital heart diseases is less than 1%. DAA makes up 46-76% of all rings. We aimed to contribute to cardiac surgery by examining and modeling the diameters in the 2D and 3D images of the patient. For 3D modeling, an open-source software program ITK-SNAP 3.8 was used, which converts 2D images from MRI, CT, and ultrasound to 3D medical image volumes. CT images of the case taken from the SECTRA system of our hospital were uploaded to ITK-SNAP and segmentation was performed. With 3D modeling, a better understanding of the stenosis in the trachea and the double arch was achieved. The ascending aorta diameter was 30 mm. There were atherosclerotic changes in the aorta and its branches. The diameter of the right aortic arch was 22.2 mm, and the diameter of the left aortic arch was 14.5 mm. Trachea diameter was found to be 17 mm/13.2 mm. Esophageal diameter was 9.8 mm. The patient had no specific complaints and no medical or surgical treatment was recommended because his physical examination was normal. We think that a better understanding of such cases in 3D may contribute to cardiovascular surgery.

The Role of CT-Angiography in the Acute Gastrointestinal Bleeding: A Pictorial Essay of Active and Obscure Findings

Gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalisation. Although 80–85% of cases of gastrointestinal bleeding resolve spontaneously, it can result in massive haemorrhage and death. The presentation of gastrointestinal bleeding can range from asymptomatic or mildly ill patients requiring only conservative treatments to severely ill patients requiring immediate intervention. Identifying the source of the bleeding can be difficult due to the wide range of potential causes, the length of the gastrointestinal tract and the intermittent nature of the bleeding. The diagnostic and therapeutic approach is fully dependent on the nature of the bleeding and the patient’s haemodynamic status. Radiologists should be aware of the appropriate uses of computed tomography angiography and other imaging modalities in patients with acute gastrointestinal bleeding, as well as the semiotics of bleeding and diagnostic pitfalls in order to appropriately diagnose and manage these patients. The learning objective of this review is to illustrate the computed tomography angiography technique, including the potential role of dual-energy computed tomography angiography, also highlighting the tips and tricks to identify the most common and uncommon features of acute gastrointestinal bleeding and its obscure form.

Gastrointestinal bleeding: imaging and interventions in cancer patients

Gastrointestinal bleeding (GIB) among cancer patients is a major source of morbidity and mortality. Although a wide variety of etiologies contribute to GIB, special considerations should be made for cancer-related factors such as the type of malignancy, location and extent of disease, hemostatic parameters, and treatment effects. Key imaging modalities used to evaluate GIB include computed tomography angiography (CTA), radionuclide imaging, and catheter-based angiography. Understanding the cancer and treatment history and recognizing the associated imaging manifestations are important for identifying the source and potential causes of GIB in cancer patients. This article will review the common clinical presentations, causes, imaging manifestations, and angiographic management of GIB in cancer patients.

Usefulness of Contrast-Enhanced CT in a Patient with Acute Phlegmonous Esophagitis: A Case Report and Literature Review

Acute phlegmonous esophagitis is a very rare, life-threatening form of esophagitis, characterized by diffuse bacterial infection and pus formation within the submucosal and muscularis layers of the esophagus. We describe a case in which contrast-enhanced chest CT was useful for evaluating the severity of phlegmonous esophagitis, which was overlooked and underestimated by endoscopy.

Intramucosal esophageal dissection caused by gastric tube insertion

We experienced a case of iatrogenic intramucosal esophageal dissection in a patient who had difficulty inserting a gastric tube. CT is useful for diagnosis.

Blunt thoracic trauma: role of chest radiography and comparison with CT - findings and literature review

In the setting of acute trauma where identification of critical injuries is time-sensitive, a portable chest radiograph is broadly accepted as an initial diagnostic test for identifying benign and life-threatening pathologies and guiding further imaging and interventions. This article describes chest radiographic findings associated with various injuries resulting from blunt chest trauma and compares the efficacy of the chest radiograph in these settings with computed tomography (CT). Common chest radiographic findings in blunt thoracic injuries will be reviewed to improve radiologic identification, expedite management, and improve trauma morbidity and mortality. This article discusses demographic information, mechanism of specific injuries, common imaging findings, imaging pearls, and pitfalls and exhibits several classic imaging findings in blunt chest trauma. Thoracic structures commonly injured in blunt trauma that will be discussed in this article include vasculature structures (aortic trauma), the heart (cardiac contusion, pericardial effusion), the esophagus (esophageal perforation), pleural space and airways (pneumothorax, hemothorax, bronchial injury), lungs (pulmonary contusion), the diaphragm (diaphragmatic rupture), and the chest wall (flail chest). Chest radiography plays an important role in the initial evaluation of blunt chest trauma. While CT imaging has a higher sensitivity than chest radiography, it remains a valuable tool due to its ability to provide rapid diagnostic information in time-sensitive trauma situations and is ubiquitously available in the trauma bay. Familiarity with the gamut of injuries that may occur as well as identification of the associated chest radiograph findings can aid in timely diagnoses and prompt management in the setting of acute blunt chest trauma.

Esophageal Intramural Haematoma related Dysphagia: A rare complication after thrombolysis

Esophageal Intramural Haematoma (EIH) is a rare entity usually caused by repeated emesis or trauma. It is diagnosed on the basis of upper gastrointestinal endoscopy and radiology. Treatment is conservative unless hemodynamic instability prevails. Use of anticoagulation or thrombolytic therapy is believed to be a risk factor rather than a causative etiology. However, a review of literature shows only few cases occurring post-thrombolysis. We report about a patient of myocardial infarction who was thrombolyzed with streptokinase. He developed hematemesis and dysphagia a few hours after thrombolysis despite ECG resolution of his ST elevation. He was diagnosed to have EIH on basis of endoscopic and computed tomographic findings. His symptoms improved within two weeks, and a repeat UGIE showed resolution of the hematoma.

Neck and mediastinal hematoma caused by a foreign body in the esophagus with diagnostic difficulties: A case report

BACKGROUND

Esophageal foreign body (FB) is a common clinical emergency. Clinically, computed tomography (CT) scans are important in the diagnosis of FBs in the esophagus. Here, we report a case of esophageal perforation and cervical hematoma, caused by a FB, whose uniqueness made rapid diagnosis difficult.

CASE SUMMARY

A 42-year-old man was transferred to our hospital with esophageal perforation, which was accompanied by cervical and mediastinal hematoma. CT scans only revealed a black shadow, approximately 2.5 cm in diameter, in the upper esophagus. After multidisciplinary discussion, he was quickly subjected to mediastinal hematoma resection, peripheral nerve compression release, esophageal FB removal and esophagectomy. Eventually, we removed a small crab with a pointed tip from his esophagus.

CONCLUSION

This was an unusual case of occurrence of sharp polygonal esophageal FBs caused by a small crab. Rapid diagnosis of this FB was difficult, mainly due to its translucent nature. Occurrence of sharp FBs, with cavities that sometimes only appear as black shadows on CT scans, can easily be mistaken for esophageal lumens. More attention should be paid to such sharp polygonal FBs.

High risk and low prevalence diseases: Esophageal perforation

INTRODUCTION

Esophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality.

OBJECTIVE

This article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence.

DISCUSSION

Esophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting.

CONCLUSIONS

An understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.

Primary repair: damage control surgery in esophageal trauma

Esophageal trauma is a rare but life-threatening event associated with high morbidity and mortality. An inadvertent esophageal perforation can rapidly contaminate the neck, mediastinum, pleural space, or abdominal cavity, resulting in sepsis or septic shock. Higher complications and mortality rates are commonly associated with adjacent organ injuries and/or delays in diagnosis or definitive management. This article aims to delineate the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia, on the surgical management of esophageal trauma following damage control principles. Esophageal injuries should always be suspected in thoracoabdominal or cervical trauma when the trajectory or mechanism suggests so. Hemodynamically stable patients should be radiologically evaluated before a surgical correction, ideally with computed tomography of the neck, chest, and abdomen. While hemodynamically unstable patients should be immediately transferred to the operating room for direct surgical control. A primary repair is the surgical management of choice in all esophageal injuries, along with endoscopic nasogastric tube placement and immediate postoperative care in the intensive care unit. We propose an easy-to-follow surgical management algorithm that sticks to the philosophy of "Less is Better" by avoiding esophagostomas.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Life-threatening bleeding from dissecting Intramural Hematoma of Esophagus (IHE) treated by trans arterial embolization

Dissecting intramural hematoma of esophagus (DIHE) is an uncommon entity, characterized by accumulation of blood within the esophageal wall and usually managed conservatively. Only in rare circumstances, DIHE is associated with massive life-threatening hemorrhage requiring emergency treatment. We present a case of DIHE associated with cardiovascular collapse and treated by transcatheter arterial embolization. Transcatheter arterial embolization is a rare treatment option for DIHE associated with hemodynamic instability and only a handful of cases have been reported in the literature.

Abdominal CT manifestations in fish bone foreign body injuries: What the radiologist needs to know

Fish bone is one of the most common foreign body ingestions encountered in the emergency department. Fish bone perforations occur most commonly in segments with acute angulation like the ileocecal region and rectosigmoid junction and can present acutely with obstruction and free air or with chronic complications like abscess and sepsis. Radiologists should be familiar with the high-risk clinical scenarios, the CT appearance of radiopaque fishbones, and the spectrum of imaging findings related to gastrointestinal (GI) tract so as to direct management and timely referral to GI endoscopists and surgeons.

CT Esophagography for Evaluation of Esophageal Perforation

Esophageal emergencies such as rupture or postoperative leak are uncommon but may be life threatening when they occur. Delay in their diagnosis and treatment may significantly increase morbidity and mortality. Causes of esophageal injury include iatrogenic (including esophagogastroduodenoscopy and stent placement), foreign body ingestion, blunt or penetrating trauma to the chest or abdomen, and forceful retching, also called Boerhaave syndrome. Although fluoroscopic esophagography remains the imaging study of choice according the American College of Radiology appropriateness criteria, CT esophagography has been shown to be at least equal to if not superior to fluoroscopic evaluation for esophageal injury. In addition, CT esophagography allows diagnosis of extraesophageal abnormalities, both as the cause of the patient's symptoms as well as incidental findings. CT esophagography also allows rapid diagnosis since the examination can be readily performed in most clinical settings and requires no direct radiologist supervision, requiring only properly trained technologists and a CT scanner. Multiple prior studies have shown the limited utility of fluoroscopic esophagography after a negative chest CT scan and the increase in accuracy after adding oral contrast agent to CT examinations, although there is considerable variability of CT esophagography protocols among institutions. Development of a CT esophagography program, utilizing a well-defined protocol with input from staff from the radiology, gastroenterology, emergency, and general surgery departments, can facilitate more rapid diagnosis and patient care, especially in overnight and emergency settings. The purpose of this article is to familiarize radiologists with CT esophagography techniques and imaging findings of emergent esophageal conditions. Online supplemental material is available for this article. ^©RSNA, 2021.

Management of Boerhaave syndrome in Australasia: a retrospective case series and systematic review of the Australasian literature

BACKGROUND

Boerhaave syndrome is a rare and life-threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non-operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature.

METHODS

A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed.

RESULTS

In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%.

CONCLUSIONS

We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.

A case of submucosal abscess of the esophagus mimicking a mediastinal abscess

We report a case of a submucosal abscess of the esophagus that required differentiation from a mediastinal abscess. A 48-year-old man presented with a chief complaint of fever and sore throat. He did not remember swallowing a foreign body, and his oral cavity showed no signs of inflammation. Contrast-enhanced computed tomography showed a low density area with enhancement in the mediastinum, especially around the esophageal wall. We planned to perform surgical drainage with the intention of performing intraoperative endoscopy from the beginning. We performed surgical drainage through a left cervical oblique incision; however, there was no exudate obtained from the mediastinal space. Despite the reported absence of accidental ingestion of a foreign substance, intraoperative endoscopy was performed that revealed a laceration in the esophageal mucosa 24 cm from the incisors. We diagnosed it as a submucosal abscess of the esophagus and prescribed parenteral antibiotics. Submucosal abscess of the esophagus can occur even in the absence of awareness of a foreign body ingestion or oral infection. In case that the abscess was not localized clearly within the outer membrane of the esophagus, the coincidental mediastinal drainage via a cervical incision and intraoperative endoscopy seemed to be useful.

Esophagography and chest CT for detection of perforated esophagus: what factors influence accuracy?

PURPOSE

To determine: whether the use of both esophagography (EG) and CT is superior to either study alone in the detection of esophageal injuries and perforations.

METHODS

Paired CT and EG performed for suspected perforated or injured native esophagus (NAE) or neo-esophagus (NEOE) were retrospectively identified and independently scored for likelihood of perforation with a Likert scale. Official reports were scored with the same scale. Retrospective study and official interpretations were assessed separately for overall diagnostic accuracy, for diagnosis of contained versus free perforation.

RESULTS

110 paired exams performed in 107 patients fulfilled inclusion criteria. Overall, combined CT and EG retrospective study interpretation was greater than EG or CT scans alone. Study EG and combined CT and EG interpretations were less sensitive for contained perforations than for free perforations. Evaluations of NAE and NEOE showed similar sensitivities. Receiver operating characteristic (ROC) curve generated from combined official CT and EG interpretations was superior to ROC from combined retrospective study interpretations.

CONCLUSIONS

Combination of EG and CT can improve sensitivity for detecting perforated intrathoracic viscus, but even with combined studies accurate diagnosis of contained perforations is challenging. Superior performance of official reports suggests that concurrent review using both modalities may improve accuracy.

Diagnostic Utility of CT and Fluoroscopic Esophagography for Suspected Esophageal Perforation in the Emergency Department

OBJECTIVE. We evaluated the diagnostic utility of CT in emergency department (ED) patients with suspected esophageal perforation and assessed whether subsequent fluoroscopic esophagography is necessary. MATERIALS AND METHODS. This retrospective study included consecutive adult patients presenting to an urban academic tertiary care ED from January 1, 2000, to August 31, 2017, who underwent CT and fluoroscopic esophagography within 1 calendar day (< 27 hours) of each other for suspected esophageal perforation. The use of oral or IV contrast material and the CT findings (i.e., pneumomediastinum, pleural effusion, pneumothorax, unexplained mediastinal fluid or stranding, esophageal wall air or frank esophageal wall disruption, or extraluminal oral contrast material) were documented. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Surgical or procedural intervention results or clinical follow-up results were the reference standard. RESULTS. One hundred three patients met the inclusion criteria. Sensitivity, specificity, PPV, and NPV for diagnosing esophageal perforation were 100.0%, 79.8%, 32.1%, and 100.0%, respectively, with CT and 77.8%, 98.9%, 87.5%, and 97.9% with fluoroscopic esophagography. Combining CT and fluoroscopic esophagography did not improve sensitivity, specificity, PPV, or NPV relative to using CT alone. The true-positive esophageal perforation rate was 8.7% for CT and 6.8% for fluoroscopic esophagography. When CT showed only pneumomediastinum (n = 51) or no pneumomediastinum (n = 14), the NPV of CT was 100.0%. CT with oral contrast material had a PPV of 38.5%, whereas CT without oral contrast material had a PPV of 26.7%. CONCLUSION. CT has a high NPV similar to that of fluoroscopic esophagography and has greater sensitivity than fluoroscopic esophagography for diagnosing suspected esophageal perforation. Fluoroscopic esophagrams do not provide additional information that changes clinical management beyond the information that CT provides. In ED patients with suspected esophageal perforation, CT with oral contrast material should be considered the initial imaging examination and can obviate fluoroscopic esophagography.

Metalophagia: Splenic artery pseudoaneurysm after foreign body ingestion and retrieval

Persistent eating of non-nutritive, nonfood substances (Pica) is seen in children and adult patients with psychiatric problems. Ingestion of multiple metallic FBs with resultant bezoar formation is rare. While many FBs are passed without complication, mucosal injury, bleeding, obstruction or perforation can occur in some cases. Endoscopic FB removal is performed in 20% of patients following FB ingestion. Generally, these are safe procedures, and very effective in extracting ingested FBs. We report, a 25-year-old male patient with a metal ingestion predominant Pica, requiring multiple prior extraction procedures (including open gastrostomy). He developed a splenic artery pseudoaneurysm following his latest endoscopic FB removal, that was successfully treated with transarterial coil embolization. The unique circumstances leading to this rare complication and its successful endovascular management make this case worthy of report.

Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology

Gastrointestinal tract (GIT) perforation is a common medical emergency associated with considerable mortality, ranging from 30 to 50%. Clinical presentation varies: oesophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations with acute severe abdominal pain, while colonic perforations tend to follow a slower progression course with secondary bacterial peritonitis or localised abscesses. A subset of patients may present with delayed symptoms, abscess mimicking an abdominal mass, or with sepsis.

Direct multidetector computed tomography (MDCT) findings support the diagnosis and localise the perforation site while ancillary findings may suggest underlying conditions that need further investigation following primary repair of ruptured bowel. MDCT findings include extraluminal gas, visible bowel wall discontinuity, extraluminal contrast, bowel wall thickening, abnormal mural enhancement, localised fat stranding and/or free fluid, as well as localised phlegmon or abscess in contained perforations.

The purpose of this article is to review the spectrum of MDCT findings encountered in GIT perforation and emphasise the MDCT and clinical clues suggestive of the underlying aetiology and localisation of perforation site.

Intramural Esophageal Abscess Complicated with Pleural Fistula: A Case Report

Intramural esophageal abscess is a rare entity caused by mucosal injury to the esophagus but without transmural perforation. The mucosal disruption provides access to the intraluminal infectious contents to traverse into the loose submucosal tissue, resulting in an intramural abscess. It is important to be well-versed in the clinical and imaging findings of this pathology in order to make a timely diagnosis. Here, we present a case of intramural esophageal abscess complicated with a pleural fistula with a focus on the radiological features of this rare entity. To our knowledge, this is the first time that an esophageal intramural abscess complicated with pleural fistula is discussed in peer-reviewed literature.

[Sudden chest pain and lower abdominal pain : The usual suspects]

CLINICAL PROBLEM

Sudden chest pain and sudden abdominal pain are among the most common reasons that lead patients to the emergency room. The heterogeneous field of possible, sometimes serious diagnoses requires a structured and rapid interdisciplinary clarification in order to be able to promptly provide patients with an adequate therapy.

STANDARD RADIOLOGICAL PROCEDURES

Knowing the "usual suspects" of sudden chest and abdominal pain enables the radiologist to quickly select the appropriate imaging method that allows a diagnosis to be made without delay. In addition to pain localization and character, age, gender, any previous illnesses and laboratory results are taken into account in the differential diagnosis.

METHODICAL INNOVATION AND EVALUATION

The technical state of computer tomography (CT) now ensures that most diagnoses can be clarified due to its excellent spatial and temporal resolution. In the abdomen, however, ultrasound should continue to be used at least for primary evaluation. Only if there is a further need for abdominal imaging afterwards is CT indicated for clarification. Magnetic resonance imaging is rarely used in the emergency setting of abdominal pain except to avoid radiation exposure in children or pregnant women.

RECOMMENDATION FOR THE PRACTICE

Knowledge of the usual diagnoses that cause sudden chest or abdominal pain, as well as knowledge of the appropriate examination procedures and classic radiological signs are essential to avoid errors and delays in the emergency diagnosis of sudden chest and abdominal pain.

Imaging of Novel Oncologic Treatments in Lung Cancer Part 2: Local Ablative Therapies

Conventional approaches to the treatment of early-stage lung cancer have focused on the use of surgical methods to remove the tumor. Recent progress in radiation therapy techniques and in the field of interventional oncology has seen the development of several novel ablative therapies that have gained widespread acceptance as alternatives to conventional surgical options in appropriately selected patients. Local control rates with stereotactic body radiation therapy for early-stage lung cancer now approach those of surgical resection, while percutaneous ablation is in widespread use for the treatment of lung cancer and oligometastatic disease for selected other malignancies. Tumors treated with targeted medical and ablative therapies can respond to treatment differently when compared with conventional therapies. For example, after stereotactic body radiation therapy, radiologic patterns of posttreatment change can mimic disease progression, and, following percutaneous ablation, the expected initial increase in the size of a treated lesion limits the utility of conventional size-based response assessment criteria. In addition, numerous treatment-related side effects have been described that are important to recognize, both to ensure appropriate treatment and to avoid misclassification as worsening tumor. Imaging plays a vital role in the assessment of patients receiving targeted ablative therapy, and it is essential that thoracic radiologists become familiar with these findings.

The Importance of the Mediastinal Triangle in Traumatic Lesions of the Aorta

Background: Trauma-induced aortic injuries continue to be an important factor in morbimortality in patients with blunt trauma. Objectives: To determine the characteristics of aortic lesions in patients with closed thoracic trauma and associated thoracic injuries. Methods: Multicenter cohort study conducted during the years 1994 to 2014 in the radiology service in the University Hospital Complex of A Coruña. Patients >15 years with closed thoracic trauma were included. Sociodemographic and clinical variables were studied in order to determine the lesion cause, location, and degree. Results: We analyzed 232 patients with a mean age of 46.9 ± 18.7 years, consisting of 81.4% males. The most frequent location was at the level of the isthmus (55.2%). The most frequent causes of injury were traffic accidents followed by falls. Patients with aortic injury had more esophageal, airway, and cardiopericardial lesions. More than 85% of the patients had lung parenchyma and/or chest wall injury, which was more prevalent among those who did not have an aortic lesion. Conclusions: Patients with trauma due to traffic accidents or being run over presented three times more risk of aortic injury than from other causes. Those with an aortic lesion also had a higher frequency of cardiopericardial, airway, and esophageal lesions.

Esophageal emergencies: WSES guidelines

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions.

OBJECTIVE OF THE REVIEW

This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions.

DISCUSSION

Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes.

CONCLUSIONS

This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.

Boerhaave’s syndrome: case report and review

Well-timed diagnostics of a spontaneous nontraumatic rupture of esophagus or Boerhaave’s syndrome, presents great difficulties because of his rarity and a variety of clinical implications. Esophagus ruptures may feign various organs pathology [2] that most often demands differential diagnostics with a stomach ulcer perforation, acute myocardial infarction, pulmonary artery embolism, aortic dissection and pancreatitis [16, 17]. The treatment can include conservative and surgical tools, but still accompanied by high mortality (up to 35%) [7]; results largely defined by the time between the moment of a rupture and start of the treatment. In addition to the review, described the experience of successful treatment of a patient with Boerhaave’s syndrome in the light of the generalized today data of world medical literature on this problem.

Accuracy of CT chest without oral contrast for ruling out esophageal perforation using fluoroscopic esophagography as reference standard: a retrospective study

PURPOSE

Esophageal perforation has a high mortality rate. Fluoroscopic esophagography (FE) is the procedure of choice for diagnosing esophageal perforation. However, FE can be difficult to perform in seriously ill patients.

METHODS

We retrospectively reviewed charts and scans of all patients who had undergone thoracic CT (TCT) without oral contrast and FE for suspicion of esophageal perforation at our hospital between October, 2010 and December, 2015. Scans were interpreted by a single consultant radiologist having > 5 years of relevant experience. Statistical analysis was performed using SPSS version 20. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TCT were computed using FE as reference standard.

RESULTS

Of 122 subjects, 106 (83%) were male and their median age was 42 [inter-quartile range (IQR) 29-53] years. Esophageal perforation was evident on FE in 15 (8%) cases. Sensitivity, specificity, PPV and NPV of TCT for detecting esophageal perforation were 100, 54.6, 23.4 and 100%, respectively. When TCT was negative (n = 107), an alternative diagnosis was evident in 65 cases.

CONCLUSION

Thoracic computed tomography (TCT) had 100% sensitivity and negative predictive value for excluding esophageal perforation. FE may be omitted in patients who have no evidence of mediastinal collection, pneumomediastinum or esophageal wall defect on TCT. However, in the presence of any of these features, FE is still necessary to confirm or exclude the presence of an esophageal perforation.

Disease- and Treatment-related Complication on F-18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Oncology Practice: A Pictorial Review

F-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) is routinely performed in oncology patients for various indications including staging, restaging, recurrence detection, and treatment response evaluation. Many disease- and treatment-related complications can be incidentally detected on PET/CT, which may be due to the complication of radiotherapy, chemotherapy, intervention, or primary tumor itself. Some of these complications could be life threatening and need urgent intervention. Therefore, these incidental findings should be recognized on PET/CT and immediately informed to the treating physicians if required urgent intervention.

Esophageal perforation due to blunt chest trauma: Difficult diagnosis because of coexisting severe disturbance of consciousness

Esophageal perforation due to blunt trauma is a rare clinical condition, and the diagnosis is often difficult because patients have few specific symptoms. Delayed diagnosis may result in a fatal clinical course due to mediastinitis and subsequent sepsis. In this article, we describe a 26-year-old man with esophageal perforation due to blunt chest trauma resulting from a motor vehicle accident. Because a severe disturbance of consciousness masked the patient's trauma-induced thoracic symptoms, we required 11h to diagnose the esophageal perforation. Therefore, the patient developed septic shock due to mediastinitis. However, his subsequent clinical course was good because of prompt combined therapy involving surgical repair and medical treatment after the diagnosis.

Endoscopic Management of Benign Esophageal Ruptures and Leaks

OPINION STATEMENT

Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.

Imaging of the oesophagus: beyond cancer

Abstract

Non-malignant oesophageal diseases are critical to recognize, but can be easily overlooked or misdiagnosed radiologically. In this paper, we cover the salient clinical features and imaging findings of non-malignant pathology of the oesophagus. We organize the many non-malignant diseases of the oesophagus into two major categories: luminal disorders and wall disorders. Luminal disorders include dilatation/narrowing (e.g. achalasia, scleroderma, and stricture) and foreign body impaction. Wall disorders include wall thickening (e.g. oesophagitis, benign neoplasms, oesophageal varices, and intramural hematoma), wall thinning/outpouching (e.g. epiphrenic diverticulum, Zenker diverticulum, and Killian-Jamieson diverticulum), wall rupture (e.g. iatrogenic perforation, Boerhaave Syndrome, and Mallory-Weiss Syndrome), and fistula formation (e.g. pericardioesophageal fistula, tracheoesophageal fistula, and aortoesophageal fistula). It is the role of the radiologist to recognize the classic imaging patterns of these non-malignant oesophageal diseases to facilitate the delivery of appropriate and prompt medical treatment.

Teaching Points

• Nonmalignant oesophageal disease can be categorised by the imaging appearance of wall and lumen.

• Scleroderma and achalasia both cause lumen dilatation via different pathophysiologic pathways.

• Oesophageal wall thickening can be inflammatory, neoplastic, traumatic, or vascular in aetiology.

CT findings of accidental fish bone ingestion and its complications

Fish bone is one of the most common accidentally ingested foreign bodies, and patients commonly present to the emergency department with nonspecific symptoms. Fortunately, most of them are asymptomatic and exit the gastrointestinal tract spontaneously. However, fish bones can get impacted in any part of the aerodigestive tract and cause symptoms. Occasionally, they are asymptomatic initially after ingestion and may present remotely at a later date with serious complications such as gastrointestinal tract perforation, obstruction, and abscess formation. Radiographs are most often negative. High degree of clinical suspicion and familiarity with CT appearance can help to detect fish bone along with any associated complications, and direct further management. We describe and illustrate various CT presentations of ingested fish bone and its complications.

Oesophageal perforation as a complication of ingested partial denture

We report herein the case of a 53-year-old female who came to the emergency room with the chief complaints of severe dysphagia and chest pain following accidental swallowing of her denture. The patient had swelling of the face, neck and eyelids with difficulty in breathing. A skull radiograph was taken, which revealed a missing partial denture from the right lower jaw. Anteroposterior radiograph of the chest showed two metallic objects in the mid-thorax, adjacent to the descending aorta. CT scan of the neck and chest revealed two metallic objects (measuring approximately 17mm each) in the middle one-third of the oesophagus (right posterolateral aspect), causing perforation of the oesophagus and leading to pneumomediastinum, and left pneumothorax with subcutaneous emphysema of the neck and chest. An emergency thoracoscopic removal of the foreign body (partial denture) was performed with subsequent repair of the oesophageal tear in the same sitting. Post surgery, the patient was shifted to intensive care unit and she recovered well over a course of time. In summary, accidental ingestion of a partial denture can lead to grave complications such as oesophageal perforation, which should be managed on an emergency basis with thoracoscopic removal of the foreign body.

Upper gastrointestinal endoscopy: expected post-procedural findings and adverse events

Complications related to endoscopy are commonly encountered in the emergency department (ED) due to an increased use of outpatient diagnostic and therapeutic upper gastrointestinal endoscopic procedures. A majority of these procedures are performed on an outpatient basis, and patients with post-procedural symptoms may return to the ED. Since these patients often undergo computed tomography (CT) for diagnosis of post-procedure complications, the emergency radiologist should be familiar with the spectrum of expected post-procedural findings, as well as common and rare complications. We present a pictorial review of post-endoscopy complications and review imaging protocols in different clinical scenarios.

Primary closure of a spontaneous esophageal rupture under hand-assisted laparoscopy: a case report

Spontaneous rupture of the esophagus, which is also known as Boerhaave’s syndrome, is a rare life-threatening condition that requires urgent surgical management. The optimal treatment involves surgical repair of the esophageal defect, which is usually accomplished via laparotomy, thoracotomy, or both, and mediastinal debridement. Here, we report a case of spontaneous rupture of the esophagus that was treated with suturing repair and drain insertion using a hand-assisted laparoscopic approach.

Oroesophageal Fish Bone Foreign Body

Fish bone foreign body (FFB) is the most frequent food-associated foreign body (FB) in adults, especially in Asia, versus meat in Western countries. The esophageal sphincter is the most common lodging site. Esophageal FB disease tends to occur more frequently in men than in women. The first diagnostic method is laryngoscopic examination. Because simple radiography of the neck has low sensitivity, if perforation or severe complications requiring surgery are expected, computed tomography should be used. The risk factors associated with poor prognosis are long time lapse after FB involvement, bone type, and longer FB (>3 cm). Bleeding and perforation are more common in FFB disease than in other FB diseases. Esophageal FB disease requires urgent treatment within 24 hours. However, FFB disease needs emergent treatment, preferably within 2 hours, and definitely within 6 hours. Esophageal FFB disease usually occurs at the physiological stricture of the esophagus. The aortic arch eminence is the second physiological stricture. If the FB penetrates the esophageal wall, a life-threatening aortoesophageal fistula can develop. Therefore, it is better to consult a thoracic surgeon prior to endoscopic removal.

Predictors of Morbidity and Mortality in Esophageal Perforation: Retrospective Study of 80 Patients

Background and Aims:

Esophageal perforation is a life-threatening disease. Factors impacting morbidity and mortality include the cause and site of the perforation, the time to diagnosis, and the therapeutic procedure. This study aimed to identify risk factors for morbidity and mortality after esophageal perforation.

Patients and Methods:

This retrospective study analyzed data collected from all patients treated for esophageal perforation at the Department of Surgery, University of Schleswig–Holstein, Luebeck Campus, from January 1986 through December 2011.

Results:

Altogether, 80 patients (52 men, 28 women; mean age 65 years) were treated. The cause of perforation was intraluminal in 44 (55%) (group A) and extraluminal in 2 (3%) (group B). Spontaneous perforations were observed in 12 (15%) (group C). Perforations were due to a preexisting esophageal disease in 22 (28%) (group D). The survival rate was higher for group A (82%) than for groups B (50%), C (57%), and D (59%). The distal third of the esophagus had the highest prevalence of perforations (49, 61%) independent of the cause. Mortality, however, was independent of the perforation site. Perforations were diagnosed within 24 h in 57% (n = 46) of patients, associated with a statistically significant lower mortality rate (p = 0.035). Altogether, 40 patients underwent non-operative treatment, and among those 27 had endoscopic treatment. Emergency thoracic surgery was performed in 40 patients: direct suture of the defect (n = 26), partial esophageal resection (n = 11), other (n = 3). Significantly higher morbidity (p = 0.007) and prolonged hospitalization (p < 0.0001) was observed among patients who underwent emergency surgery. Mortality was higher in the surgical group (14/40) than in the non-operative treatment group (9/40) but without statistical significance.

Conclusion:

Intraluminal perforations, rapid initiation of therapy, and non-operative treatment were associated with favorable outcomes. The perforation site did not have an impact on outcomes. Esophageal resection was associated with high mortality.