High risk and low prevalence diseases: Esophageal perforation

Spontaneous esophageal rupture resulting in formation of multiple pulmonary artery pseudoaneurysms: A case report

Esophageal rupture and pulmonary artery pseudoaneurysm are 2 rare but life-threatening conditions that are challenging to detect but require prompt intervention once diagnosed. The present case describes a patient with spontaneous esophageal rupture resulting in necrotizing pneumonia and multiple PAP that were ultimately managed via endovascular embolization combined with surgical resection. Although atypical, it emphasizes the need for a high degree of clinical suspicion when either of these diagnoses are on the differential and additionally illustrates another scenario in which interventional radiology and surgery can collaborate to optimize patient care.

Optimizing CT Esophagography: Ex Vivo Study on Contrast Ratios, Image Quality, and Dual-Energy Benefits

This study aimed to optimize CT esophagography by identifying effective oral contrast dilution ratios and exploring the advantages of dual-energy CT (DECT) over conventional CT for improving image quality. Ex vivo experiments using iodine contrast agents (320-400 mgI/mL) at 21 dilution ratios were scanned at three voltages, with additional dual-energy scans generating various reconstruction images. Image quality was assessed both objectively and subjectively. The study found significant variability in image quality across different dilution ratios. Specific dilution ratios that produced image quality comparable to the control group (a commercial oral contrast agent) and those meeting the standards for clinical diagnosis and high-quality images were identified based on image quality assessments. Recommendations for preparing 100 mL of oral contrast solution were provided, such as for achieving high-quality images at a scanning voltage of 100 kVp: the optimal dilution ratios are 1:6 to 1:19 for 320 mgI/mL, and 1:8 to 1:19 for 350 to 400 mgI/mL. Additionally, beam-hardening artifacts were significantly reduced in DECT images. These findings provide valuable guidance for improving CT esophagography protocols.

Hydropneumopericardium Due to a Traumatic Esophageal-Pericardial Fistula

Esophago-pericardial fistula is a rare, life-threatening condition, usually arising as a complication of benign esophageal disorders or iatrogenic causes. Prompt diagnosis via multimodality imaging is crucial, with computed tomography being the most sensitive. Management varies based on severity, with a growing trend toward early endoscopic interventions, which result in improved outcomes.

Factors Influencing the Fasting Time in Adult Patients After the Endoscopic Management of Sharp Esophageal Foreign Bodies

BACKGROUND

Sharp esophageal foreign body (SEFB) impaction can cause varying degrees of damage to the esophagus. There are few studies analyzing the postoperative fasting time in SEFB patients.

METHODS

We retrospectively collected 835 SEFB patients. According to the fasting time after the endoscopic removal (ER) of SEFBs, the patients were divided into two groups: short fasting time (SFT, fasted ≤24 h) and long fasting time (LFT, fasted >24 h).

RESULTS

There were 216 and 619 patients in the SFT and LFT group, respectively. The average age of the SFT group (52.97 years) was younger than that of the LFT group (55.96 years) (p = 0.025). The LFT group had lower proportion of duration of impaction (DOI) within 12 hours (14.2% vs 22.2%, p = 0.006) and erosion rates (89.0% vs 94.0%, p = 0.034) as well as higher proportion of esophageal perforation (19.5 vs 6.5%, p = 0.010) and patients who got intravenous anesthesia (63.78% vs 31.9%, p = 0.000) than the SFT group. The longest diameter of the foreign body (Lmax) in the LFT group (2.60 ± 1.01 cm) was greater than that in the SFT group (2.41 ± 0.83 cm; p = 0.01). Multivariate regression analysis found that age (OR = 1.726[1.208-2.465], p = 0.003), DOI (OR = 1.793[1.175-2.737], p = 0.007), Lmax (OR = 1.477[1.033-2.111], p = 0.032), perforation (OR = 3.698[2.038-6.710]; p < 0.01) and intravenous anesthesia (OR = 3.734[2.642-5.278]; p < 0.01) were the independent factors that prolonged fasting time in patients with SEFBs, while esophageal mucosal erosion (OR = 0.433[0.229-0.820]; p = 0.01) was the influencing factor leading to shortened fasting time.

CONCLUSION

For the first time, we analyzed factors influencing the fasting time after ER in SEFB patients. Age, DOI, Lmax, perforation and intravenous anesthesia were risk factors for a prolonged postoperative fasting time.

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.

Esophageal Perforation

Esophageal perforation is a rare but fatal disease process that requires prompt diagnosis and treatment. Surgery has historically been required for treatment; however, there is currently a shift toward endoscopic management. Although no randomized controlled trials exist to compare patient outcomes, many case series and systematic analyses describe their indications, efficacy, and safety profile. Endoscopic stenting and endoscopic vacuum therapy are the 2 therapies most widely described across a diverse patient population and appear to be safe and effective when treating esophageal perforation, in the proper clinical setting. Guidelines and scoring systems exist to help direct management and stratify patient risk.

Risk factors for the poor prognosis of Benign esophageal perforation: 8-year experience

BACKGROUND

Esophageal perforation (EP) has a high mortality rate and poor prognosis. This single-center retrospective study aims to analyze the related risk factors for benign EP.

METHODS

We retrospectively analyzed 135 patients with benign EP admitted to the First Affiliated Hospital of Nanchang University from January 2012 to December 2020. Univariate and multivariate logistic analysis were performed to estimate risk factors for prognosis of esophageal perforation patients.

RESULTS

There were 118 EP patients with foreign body ingestion and 17 patients with nonforeign body ingestion. Fish bones (78/118) were the most common foreign body and most of the nonforeign EPs were caused by spontaneous esophageal rupture (14/17). Foreign body perforations occurred mostly in the upper thoracic segment (70/118) and middle thoracic segment (31/118), and spontaneous esophageal ruptures occurred mostly in the lower thoracic segment (15/17). Fifteen patients (11.1%) died during hospitalization or within one month of discharge. Multivariable logistic regression analysis showed that high white blood cell (WBC) levels [odds ratio (OR) = 2.229, 95% confidential interval (CI): 0.776-6.403, P = 0.025], chest or mediastinal emphysema (OR = 7.609, 95% CI: 2.418-23.946, P = 0.001), and time to treatment > 72 h (OR = 3.407, 95% CI: 0.674-17.233, P = 0.018) were independent risk factors for poor prognosis.

CONCLUSION

Foreign body was the major reason for benign EP. High WBC level, chest or mediastinal emphysema and time to treatment > 72 h were risk factors for poor prognosis.