Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary?

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.

Pneumomediastinum complicating diabetic ketoacidosis

Pneumomediastinum is an uncommon finding in patients with diabetic ketoacidosis (DKA) and may occur spontaneously or secondary to an effort rupture of the oesophagus. Excluding oesophageal rupture is important, as delaying treatment increases the risk of mortality. We discuss a case of DKA complicated by vomiting, pneumomediastinum, pneumopericardium and air in the epidural space. Instead of fluoroscopic oesophagography, chest CT was used to investigate oesophageal rupture. We present an overview of case reports and retrospective studies illustrating the utility of chest CT in the investigation of oesophageal rupture over fluoroscopic oesophagography.

CT Evaluation of the Esophagus: The Role of CT Imaging and CT Imaging Findings in Diagnosing Esophageal Abnormalities

Esophageal disorders are commonly encountered by radiologists on computed tomography. Characteristic computed tomography findings of various esophageal pathologies have been extensively described and are important for the radiologist to know to facilitate accurate and timely diagnosis. Esophageal disorders can be broadly classified as infectious and inflammatory, congenital/structural, or neoplastic. This paper reviews the most common presentations of various esophageal pathologies within each classification.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

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.

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.

Mediastinal fluid as a predictor for esophageal perforation as the cause of pneumomediastinum

PURPOSE

Pneumomediastinum is not an uncommon finding on emergency CTs and is seen in a variety of settings, including acute trauma, recent repeated emesis and recent thoracic surgery, and after EGD (Kouritas et al. J Thorac Dis 7(Suppl 1):S44-S49, 2015). The purpose of this study was to examine cases of CT pneumomediastinum for distinguishing features which could support or exclude esophageal injury as a cause, which in turn could help guide evaluation of these patients.

METHODS

CT chest scans showing pneumomediastinum performed in the emergency department between January 2013 and December 2018 were included. The presence or absence of fluid within the mediastinal compartments was correlated with esophageal perforation and subdivided into the clinical scenarios of trauma, suspected Boerhaave's syndrome, recent surgery or EGD, and other. Accuracy of this finding was compared with fluoroscopic esophagography.

RESULTS

Twenty-two cases of esophageal perforation were identified out of a total of 324 included cases. The cases were subdivided into four categories: trauma, suspected Boerhaave syndrome, suspected iatrogenic perforation from recent procedure or surgery, and other. Two hundred fourteen cases of pneumomediastinum occurred in the setting of trauma, and 2 had esophageal perforation. Both showed mediastinal fluid. Twenty-two cases had mediastinal fluid without perforation. Seventeen cases of pneumomediastinum occurred in the setting of suspected Boerhaaves, and 3 had esophageal perforation. Every case with esophageal perforation had mediastinal fluid, and every case without perforation had no mediastinal fluid. Nine cases of pneumomediastinum occurred in the setting of suspected iatrogenic perforation after recent surgery or procedure. Six cases had esophageal perforation, and 5 of these had mediastinal fluid. All three cases without perforation also had mediastinal fluid. Eighty-six cases were classified as other and included a variety of clinical histories. This category contained 8 esophageal perforations, 7 of which had mediastinal fluid. One case of mediastinal fluid was not associated with esophageal perforation in this category.

CONCLUSION

The presence of mediastinal fluid, specifically within the visceral compartment, strongly suggests esophageal injury, and its absence strongly argues against it. An important caveat is in the setting of recent surgery, in which mediastinal fluid can be seen normally. An esophagography study can supplement the evaluation if there is a discrepancy between the clinical suspicion and the original CT findings.

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.

Trans-hiatal repair for Oesophageal and Junctional perforation: a case series

Background

Oesophageal perforation is a life-threatening condition that requires urgent intervention. Surgical repair is recommended within 24 h of onset to minimise mortality risk, traditionally via an open thoracotomy or a laparotomy. Primary oesophageal repair via a laparoscopic trans-hiatal approach has been seldomly reported due to concerns of inadequate eradication of soilage in the mediastinum and pleural space, as well as poor access and an increased operative time in an unwell population.

Case presentation

We report a case series of 3 oesophageal and junctional perforations with varying presentations, demonstrating how the laparoscopic trans-hiatal approach can be used successfully to manage oesophageal perforations.

Conclusions

Laparoscopic trans-hiatal repair is an attractive option for oesophageal and junctional perforations, in haemodynamically stable surgical candidates, in the absence of gross contamination of the thoracic cavity.

Boerhaave Syndrome Causing Bilateral Empyemas

Boerhaave syndrome is a perforation of the esophagus caused by a sudden increase in intraluminal pressure. It is known to be associated with left-sided pleural effusion and mediastinitis, but rarely presents with bilateral effusion. Its association with the presence of a hiatal hernia is unclear. We present a patient with a hiatal hernia who developed bilateral empyemas because of Boerhaave syndrome and was treated with an endoscopically placed esophageal stent.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

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.

Management of esophageal injuries secondary to trauma

Traumatic esophageal injuries occur less than 10% of the time in the setting of blunt or penetrating trauma. The purpose of this literature review is to provide an update on the most recent changes involving the diagnosis and treatment of esophageal injuries. A literature search was conducted using PubMed, to identify articles written in English language with the terms "non- iatrogenic", "esophageal", "trauma", "diagnosis", "management", and "prognosis". Case reports and articles involving non-traumatic esophageal perforations were excluded. Fifty pertinent articles in English language from 1947 to 2015 were selected for review. Based on the review of all articles, we designed a diagnostic and therapeutic algorithm to facilitate the diagnosis and management of the traumatic esophageal injury.

Scary gas: a spectrum of soft tissue gas encountered in the axial body (part II)

Ectopic gas in the mediastinum, subperitoneal abdomen, and superficial soft tissues is concerning and can be seen in the setting of trauma, iatrogenic injuries, infection, and inflammation. It can spread along different dissection pathways and may present remotely from the involved organ as described in part one. Recognition of ectopic gas on imaging and differentiating it from other causes of benign gas is very important as these conditions associated with ectopic gas can lead to rapid patient deterioration and usually require urgent surgery. In part two, the different causes of ectopic and benign gas in the torso are reviewed as well as the imaging features that can help to narrow the differential diagnosis.

A dental nightmare, resolved: what a radiologist needs to know when consulted about ingestion of dental foreign body material

Ingestion of dental foreign bodies, while relatively rare, may cause serious, and occasionally fatal, injuries to the airways and gastrointestinal tract. Numerous case reports are available describing the clinical course of such ingestions. The aim of this paper is to develop concise, practical recommendations to aid radiologists in providing clinically relevant diagnostic information, thereby accelerating detection and management of acute ingestion of dental material.

Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications?

BACKGROUND

Many of the acute alterations after peroral endoscopic myotomy (POEM) may be of little clinical significance, while others may herald major clinical problems. The question whether pneumomediastinum/pneumoperitoneum is a normal postoperative finding after POEM, or should be regarded as a sign of a complication needs to be evaluated. Familiarity with these findings in computed tomography (CT) is essential for radiologists.

PURPOSE

To evaluate whether or not pneumomediastinum/pneumoperitoneum detected by chest CT is a sign of a complication after POEM using CO2 insufflation for esophageal achalasia.

MATERIAL AND METHODS

One hundred and eight patients with esophageal achalasia who underwent chest CT within 30 hours after POEM were included. CT findings were retrospectively reviewed by two radiologists in consensus. The correlation between pneumomediastinum and/or pneumoperitoneum shown on CT and the development of complications was analyzed.

RESULTS

Abnormal findings were identified on post-treatment CT, including pneumomediastinum and/or pneumoperitoneum (53.7%, 58/108), pneumothorax (0.9%, 1/108), subcutaneous emphysema (29.6%, 32/108), pleural effusion (69.4%, 75/108), segmental atelectasis of lung tissue (29.6%, 32/108), minor inflammation of lungs (69.4%, 75/108), and ascites (0.9%, 1/108). Pneumomediastinum and pneumoperitoneum were observed simultaneously in 29 cases. The incidence rate of mild complications was high (79.6%, 86/108), while the rate of severe complications was low (2.8%, 3/108). There was no significant correlation between the occurrence of pneumomediastinum and/or pneumoperitoneum on CT and the development of complications (P = 0.542), or the development of severe complications including delayed hemorrhage, esophageal perforation, and retroperitoneal abscess.

CONCLUSION

Pneumomediastinum and pneumoperitoneum detected by CT occur frequently after POEM and may be regarded as normal postoperative changes.