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Ninivaggi V, Bianchi G, Fabbri A, Maggi F, Costantini E, Zugaro L. Gastrointestinal and genitourinary fluoroscopy: a pictorial essay of a useful evergreen technique. Abdom Radiol (NY) 2025; 50:2370-2379. [PMID: 39613871 DOI: 10.1007/s00261-024-04723-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Revised: 11/22/2024] [Accepted: 11/23/2024] [Indexed: 12/01/2024]
Abstract
Until recently, the use of direct contrast examinations with oral or intracavitary contrast agents was widespread in all general radiology departments. It provided significant answers to multiple clinical questions on the enteric organs and their mucosal surfaces. With the increased availability of CT and MRI, which also allow for the study of walls, as well as the accessibility of endoscopic examinations, the request and execution of fluoroscopy contrast studies have fallen considerably. Despite this, fluoroscopy contrast exams are still useful in specific clinical queries; therefore, radiologists should be able to provide their diagnostic contributions. This pictorial essay of clinical cases collected in our radiology department demonstrates the current demand for these examinations, the variety of the clinical questions we are called upon to answer and the need for continued expertise in execution and diagnostic interpretation of such studies.
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Affiliation(s)
- Valeria Ninivaggi
- Department of Radiological Sciences, Institute of Radiology, Avezzano Hospital, Avezzano (AQ), Italy.
| | - Giampaolo Bianchi
- Department of Radiological Sciences, Institute of Radiology, Avezzano Hospital, Avezzano (AQ), Italy
| | - Antonello Fabbri
- Department of Radiological Sciences, Institute of Radiology, Avezzano Hospital, Avezzano (AQ), Italy
| | - Fabio Maggi
- Department of Radiological Sciences, Institute of Radiology, Avezzano Hospital, Avezzano (AQ), Italy
| | - Emanuele Costantini
- Department of Radiological Sciences, Institute of Radiology, Avezzano Hospital, Avezzano (AQ), Italy
| | - Luigi Zugaro
- Department of Radiological Sciences, Institute of Radiology, Avezzano Hospital, Avezzano (AQ), Italy
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Magradze G, Knopf A, Becker C, Ketterer MC. Etiology and therapy of pharyngeal perforations. Eur Arch Otorhinolaryngol 2025; 282:2549-2555. [PMID: 39627581 PMCID: PMC12055951 DOI: 10.1007/s00405-024-09115-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Accepted: 11/20/2024] [Indexed: 05/07/2025]
Abstract
OBJECTIVE The primary aim of this study is to evaluate the impact of diagnostic procedures and treatment interventions performed at our medical institution on the final outcomes and survival rates of patients with iatrogenic and traumatic pharyngeal perforation (PP). MATERIALS AND METHODS We reviewed the medical records of 36 patients with iatrogenic and trauma-induced PP who were treated at the Quaternary Medical Center of Otorhinolaryngology between 2010 and 2020. Comorbidities were classified according to the Age-adjusted Charlson Comorbidity Index (ACCI) scoring system, and postoperative complications were classified according to the Clavien and Dindo scoring system. RESULTS Of the 36 patients, 15 (41.7%) were male and 21 (58.3%) were female. The median age was 73 years, and PP was typically diagnosed within one day. Notably, the perforation site was identified in the hypopharynx in 29 (80.5%) patients. The median ACCI score was 4, with the most frequent ACCI score observed being 5. During the treatment course, 17 patients (47.2%) experienced complications, with 9 of these patients experiencing grade IV complications according to the Clavien and Dindo classification. CONCLUSION Our study showed that patients with hypopharyngeal perforations have an almost 42-fold higher risk of mortality during hospitalization compared to those with epipharyngeal or oropharyngeal perforations, though results are limited by the small sample size and the variable dates. Additionally, neurosurgery of the cervical spine, transesophageal echocardiography, and diverticular surgery emerged as procedures carrying the highest risk for pharyngeal perforations. Within our patient cohort, 4 patients (11.11%, all female) died during the treatment course.
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Affiliation(s)
- Givi Magradze
- Department of Otorhinolaryngology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Department of Otorhinolaryngology- Head and Neck Surgery, University Medical Centre Freiburg, Killianstrasse 5, 79106, Freiburg, Germany.
| | - Andreas Knopf
- Department of Otorhinolaryngology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Becker
- Department of Otorhinolaryngology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manuel Christoph Ketterer
- Department of Otorhinolaryngology, Medical Center- University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Yu GZ, Ly M, Beal MA, Naylor A, Bhalla S, Raptis DA. Imaging the Spectrum of Mediastinitis. Semin Roentgenol 2025; 60:161-169. [PMID: 40280656 DOI: 10.1053/j.ro.2025.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 12/29/2024] [Accepted: 01/14/2025] [Indexed: 04/29/2025]
Affiliation(s)
- Gary Z Yu
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | - Maria Ly
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | - Michael A Beal
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | - Adam Naylor
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO
| | - Demetrios A Raptis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO.
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Malach L, Byerly S, Evans CR, Babowice J, Holliday T, Lenart EK, Soule S, Kerwin AJ, Filiberto DM. Penetrating aerodigestive injuries and the role of computed tomography esophagography. Am J Surg 2025; 239:116061. [PMID: 39567276 DOI: 10.1016/j.amjsurg.2024.116061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/25/2024] [Accepted: 10/28/2024] [Indexed: 11/22/2024]
Abstract
BACKGROUND Penetrating neck injuries can be fatal if not quickly identified; however, operative intervention is not always necessary. Prompt evaluation with imaging studies aids in identifying patients who need intervention. METHODS A retrospective, single-center study of patients with PNI from 2017 to 2022 was performed. Management, outcomes, and mortality were compared. Sensitivity and specificity were calculated for imaging studies performed. RESULTS Of 436 patients with PNI, 72 had an aerodigestive injury: 42(58 %) underwent operative management, and 30(42 %) underwent nonoperative management. There was no difference in mortality. The sensitivity and specificity of computed tomography (CT) esophagography for hypopharyngeal/esophageal injury were 100 %. The sensitivity and specificity of fluoroscopic esophagography were 71 % and 99 %. The sensitivity and specificity of combined fluoroscopic esophagography and flexible esophagoscopy were 100 %. CONCLUSION In select patients with penetrating aerodigestive injuries, nonoperative management is safe. CT esophagography alone may be sufficient to identify a hypopharyngeal/esophageal injury.
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Affiliation(s)
- Lillian Malach
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States.
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
| | - Cory R Evans
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
| | - James Babowice
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
| | - Tyler Holliday
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
| | - Emily K Lenart
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
| | - Sara Soule
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
| | - Andrew J Kerwin
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
| | - Dina M Filiberto
- Department of Surgery, University of Tennessee Health Sciences Center, Memphis, TN. 910 Madison Ave. 2nd Floor Memphis, TN, 38163, United States
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Hao L, Chen X, Jiang Y, Wang Y, Hu X, Hu D, Li Z, Shen Y. Optimizing CT Esophagography: Ex Vivo Study on Contrast Ratios, Image Quality, and Dual-Energy Benefits. Bioengineering (Basel) 2024; 11:1300. [PMID: 39768118 PMCID: PMC11727102 DOI: 10.3390/bioengineering11121300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Revised: 12/12/2024] [Accepted: 12/18/2024] [Indexed: 01/16/2025] Open
Abstract
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.
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Affiliation(s)
- Luwen Hao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.H.); (Y.J.); (Y.W.); (X.H.); (D.H.); (Z.L.)
- Department of Radiology, Taikang Tongji (Wuhan) Hospital, Wuhan 430050, China;
| | - Xin Chen
- Department of Radiology, Taikang Tongji (Wuhan) Hospital, Wuhan 430050, China;
- School of Public Health, Medical College, Wuhan University of Science and Technology, Wuhan 430065, China
| | - Yuchen Jiang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.H.); (Y.J.); (Y.W.); (X.H.); (D.H.); (Z.L.)
| | - Yufan Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.H.); (Y.J.); (Y.W.); (X.H.); (D.H.); (Z.L.)
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.H.); (Y.J.); (Y.W.); (X.H.); (D.H.); (Z.L.)
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.H.); (Y.J.); (Y.W.); (X.H.); (D.H.); (Z.L.)
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.H.); (Y.J.); (Y.W.); (X.H.); (D.H.); (Z.L.)
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (L.H.); (Y.J.); (Y.W.); (X.H.); (D.H.); (Z.L.)
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Grewal J, Gillaspie EA. Pneumomediastinum. Thorac Surg Clin 2024; 34:309-319. [PMID: 39332856 DOI: 10.1016/j.thorsurg.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
Pneumomediastinum, air within the mediastinum, is the manifestation of a variety of causes including those that are benign and some resulting in severe morbidity and even mortality. This article reviews the epidemiology, etiology, and pathophysiology of pneumomediastinum as an independent pathologic and physiologic entity, as well as reviews the workup and management of those patients who are diagnosed with pneumomediastinum.
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Affiliation(s)
- Jordan Grewal
- Department of General Surgery, Vanderbilt University Medical Center, Nashville TN, USA
| | - Erin Alexis Gillaspie
- Department of Thoracic Surgery, Creighton University Medical Center, Omaha, NE, USA.
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Benson J, Boutros C, Khan SZ, Lyons J, Hashimoto DA, Marks JM. Evaluation of postoperative esophagram following peroral endoscopic myotomy (POEM). Surg Endosc 2024; 38:5148-5152. [PMID: 39039293 DOI: 10.1007/s00464-024-11023-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/30/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION The routine use of post-operative esophogram has come under evaluation for multiple upper GI surgeries such as with bariatric surgery and gastric resections. A major complication following Per Oral Endoscopic Myotomy (POEM) is a leak from the myotomy site. A post-operative contrast esophogram is often utilized to evaluate the presence of a leak, however it is not a standardized care practice for all patients. Presently it is selectively performed depending on physician assessment intra-operatively. This project will evaluate the necessity of post-operative contrast esophogram following POEM. MATERIALS AND METHODS We retrospectively reviewed 277 patients diagnosed with achalasia who underwent POEM by two surgeons from 2011 to 2022. 173 patients met the inclusion criteria. A post-operative esophogram was used for the evaluation of a leak. Post-operative esophagram were selectively performed on day 1 following surgery using a water-soluble material. Data was evaluated using Stata. RESULTS There were 3 detected leaks in the group that underwent esophagrams compared to the non-esophagram group in the early post-operative period. The overall complication rate was 5.5% in the non-esophagram versus 7.9% in the esophagram group. Length of stay was 1.48 days in the non-UGI vs 1.76 days in the esophagram group. Readmission rate was 10.9% in non-esophagram versus 8.7% in esophagram group. CONCLUSION There was no statistically significant difference in outcomes in patients undergoing POEM who received post-operative esophagram verses patients who did not receive post-operative esophagram. The routine use of a contrast esophogram to detect a leak following POEM may not be justified. This study suggests that esophagrams should be performed depending on the clinical signs/symptoms post-operatively that would warrant imaging and intervention.
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Affiliation(s)
- Jamie Benson
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
- Case Western Reserve University, Cleveland, OH, USA.
| | - Christina Boutros
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Saher-Zahra Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Joshua Lyons
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Daniel A Hashimoto
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
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Siletz A, Inaba K. Diagnostic approach to penetrating neck trauma: What you need to know. J Trauma Acute Care Surg 2024; 97:175-182. [PMID: 38523116 DOI: 10.1097/ta.0000000000004292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Diagnostic evaluation of penetrating neck trauma has evolved considerably over the last several decades. The contemporary approach to these injuries is based primarily on clinical signs of injury and multidetector computed tomographic angiography. The neck is evaluated as a unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries. This "no-zone" approach safely spares many patients from negative explorations and unnecessary invasive tests. The purpose of this review is to describe an evidence-based approach to the diagnostic evaluation of penetrating neck trauma, including indications for adjunctive testing beyond physical examination and multidetector computed tomographic angiography. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
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Affiliation(s)
- Anaar Siletz
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (A.S., K.I.), Los Angeles General Medical Center; and Keck School of Medicine (A.S., K.I.), University of Southern California, Los Angeles, California
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Alnaimat S, Nasr LA, Biederman RWW. Novel use of dynamic MR hydrography to rule out esophageal perforation post atrial fibrillation ablation in a patient with anaphylaxis to gadolinium. Magn Reson Imaging 2024; 109:96-99. [PMID: 38467266 DOI: 10.1016/j.mri.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/13/2024]
Abstract
Esophageal thermal injury is one of the most devastating complications of atrial radiofrequency ablation, and its diagnosis can be challenging. In this report, we highlight the novel use of free water as a contrast material to better visualize the esophageal lumen in a patient with anaphylaxis to Iodinated contrast media and Gadolinium who recently underwent atrial fibrillation ablation. This becomes particularly handy in patients with contrast allergy, and further emphasizes the role of multimodality imaging.
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Affiliation(s)
- Saed Alnaimat
- Allegheny General Hospital, Center of Cardiac MRI, 320 E North Ave, Pittsburgh, PA 15212, United States of America.
| | - Layla A Nasr
- Allegheny General Hospital, Department of Radiology, 320 E North Ave, Pittsburgh, PA 15212, United States of America
| | - Robert W W Biederman
- West Virginia University School of Medicine, 64 Medical Center Dr, Morgantown, WV 26506, United States of America; Carnegie Mellon University, Bioengineering Department, 5000 Forbes Ave, Pittsburgh, PA 15213, United States of America; Medical University of South Carolina and Roper/SF Hospital, 268 Calhoun St, Charleston, SC 29425, United States of America
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Bhojani F, Shafqat G, Zafar U, Khan A. 'Bubbles and esophagus: A tale of unexpected and otherwise unexplained pain'. Radiol Case Rep 2024; 19:2043-2047. [PMID: 38444597 PMCID: PMC10914552 DOI: 10.1016/j.radcr.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 03/07/2024] Open
Abstract
Boerhaave's syndrome is a potentially fatal emergency, typically induced by forceful retching, which leads to increased intra-esophageal pressure. It commonly presents with vague symptoms such as chest pain or more classic symptoms like subcutaneous emphysema and vomiting. We present an unusual case of Boerhaave syndrome secondary to rapid and excessive intake of carbonated drinks in a 22-year-old male, who presented to our emergency department with atypical symptoms of fever and shortness of breath. Imaging studies showed left-sided hydropneumothorax with an esophageal pleural fistula, and multidisciplinary teams were involved in the patient's management.
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Affiliation(s)
- Fatima Bhojani
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Gulnaz Shafqat
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Uffan Zafar
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Anam Khan
- Department of Radiology, Aga Khan University, Karachi, Pakistan
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11
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Evans BA, Craig WY, Cinelli CM, Siegel SG. CT esophagogram in the emergency setting: typical findings and suggested workflow. Emerg Radiol 2024; 31:33-44. [PMID: 38093143 DOI: 10.1007/s10140-023-02193-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/27/2023] [Indexed: 02/02/2024]
Abstract
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.
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Affiliation(s)
- Brad A Evans
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA.
- University of Wisconsin, 750 Highland Ave., Madison, WI, 53705, USA.
| | - Wendy Y Craig
- MaineHealth Institute for Research, 81 Research Drive, Scarborough, ME, 04074, USA
| | - Christina M Cinelli
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
- Spectrum Healthcare Partners, 324 Gannett Dr. Suite 200, South Portland, ME, 04106, USA
| | - Sharon G Siegel
- Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
- Spectrum Healthcare Partners, 324 Gannett Dr. Suite 200, South Portland, ME, 04106, USA
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Ivanauskas E, Jones KA. Not Your Typical Sore Throat-A Case Report on Delayed Complications From Cervical Spinal Surgery. Ann Emerg Med 2024; 83:68-71. [PMID: 37676180 DOI: 10.1016/j.annemergmed.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 09/08/2023]
Abstract
Esophageal perforation is an uncommon illness with a mortality rate as high as 50%. It is most frequently caused by iatrogenic instrumentation for both diagnostic and therapeutic purposes. Noniatrogenic spontaneous ruptures account for 15% of cases, followed by traumatic injury and rupture secondary to a foreign body.1 Sore throat is a common emergency medicine complaint with an array of causes and severity of pathology. We report a case of a sore throat resulting from esophageal perforation and prevertebral abscess as delayed complications from an anterior cervical surgery.
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Affiliation(s)
- Emma Ivanauskas
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Kerin A Jones
- Department of Emergency Medicine, Wayne State University, Detroit, MI.
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13
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Hinen SP, Griffith JP, Chamberlin J, Waltz J, Kocher M, Krull V, Young T, Litvin CB, Varga-Szemes A, Hardie AD. Dual-energy CT iodine overlay improves efficiency of oral contrast leak assessment. Acta Radiol 2023; 64:2357-2362. [PMID: 37157189 DOI: 10.1177/02841851231172771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Evaluation for gastrointestinal leak is a frequent imaging indication, and dual-energy computed tomography (DECT) with oral or rectally administered contrast can be used to improve efficiency and diagnostic confidence. PURPOSE To assess the value of the DECT iodine overlay (IO) reconstruction as a stand-alone image set compared to routine CT in assessing oral or rectal contrast leak from the gastrointestinal system. MATERIAL AND METHODS A blinded, retrospective audit study was performed by three readers who each interpreted 50 studies performed for assessment of oral or rectal contrast leak that were acquired using DECT. Each reader independently assessed both the routine CT images and the images of the reconstructed IO for contrast leak in random order with a six-week "wash-out period" between readings. Clinical follow-up provided the reference standard. Readers recorded the presence/absence of a leak, diagnostic confidence, image quality score, and interpretation time for each image set. RESULTS Pooled data for overall accuracy in identification of a leak increased from 0.81 (95% confidence interval [CI]=0.74-0.87) for routine CT to 0.91 (95% CI=0.85-0.95) with IO, and the area under the curve (AUC) was significantly higher for IO than routine CT (P = 0.015). Readers required significantly less time to interpret IO than routine CT (median improvement of 12.5 s per image using pooled data; P < 0.001) while maintaining diagnostic confidence and perceived image quality. CONCLUSION Use of DECT IO reconstructions for identification of oral or rectal contrast leak requires less time to interpret than routine CT with improved accuracy and maintained diagnostic confidence and perceived image quality.
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Affiliation(s)
- Shaun P Hinen
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Joseph P Griffith
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Jordan Chamberlin
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey Waltz
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Madison Kocher
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Veronica Krull
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Tristan Young
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Cara B Litvin
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Akos Varga-Szemes
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Andrew D Hardie
- Department of Radiology and Radiological Sciences, The Medical University of South Carolina, Charleston, SC, USA
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Zethof S, Borstlap C, Vroomans M, Groenendijk M. Pneumomediastinum complicating diabetic ketoacidosis. BMJ Case Rep 2023; 16:e255018. [PMID: 37137549 PMCID: PMC10163478 DOI: 10.1136/bcr-2023-255018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/05/2023] Open
Abstract
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.
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Affiliation(s)
- Siem Zethof
- Intensive Care, Alrijne Zorggroep, Leiderdorp, Netherlands
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15
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Buchanan ME, Fishman EK, Azadi JR. CT Evaluation of the Esophagus: The Role of CT Imaging and CT Imaging Findings in Diagnosing Esophageal Abnormalities. Curr Probl Diagn Radiol 2023; 52:289-299. [PMID: 37045693 DOI: 10.1067/j.cpradiol.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/16/2023] [Indexed: 04/14/2023]
Abstract
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.
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Affiliation(s)
- Mary E Buchanan
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Elliot K Fishman
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Javad R Azadi
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD.
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16
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Overcast WB, Taylor C, Capps AE, Steenburg SD. Utility of fluoroscopic oesophagography in the setting of spontaneous and blunt traumatic pneumomediastinum. Clin Radiol 2023; 78:e214-e220. [PMID: 36572600 DOI: 10.1016/j.crad.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 12/26/2022]
Abstract
AIM To determine the incidence of positive fluoroscopic oesophagography in patients presenting with spontaneous or blunt traumatic pneumomediastinum. MATERIALS AND METHODS Retrospective chart review was performed on patients who underwent fluoroscopic oesophagography for spontaneous or blunt traumatic pneumomediastinum between 2001-2019. Patients were excluded for history of oesophageal surgery, penetrating trauma, oesophageal cancer, or tracheal/oesophageal instrumentation. RESULTS Two hundred and fifty-two patients met the inclusion criteria; 170 presented with spontaneous pneumomediastinum and 82 presented with blunt traumatic pneumomediastinum. Fluoroscopic oesophagography was positive in eight patients with spontaneous pneumomediastinum, for a positivity rate of 4.7% (8/170). There was one false-negative case in a patient who presented with spontaneous pneumomediastinum and was found to have a non-full-thickness oesophageal injury on endoscopy. Fluoroscopic oesophagography was negative in all patients with blunt traumatic pneumomediastinum (0/82). The sensitivity and specificity of fluoroscopic oesophagography were 88.9% (8/9) and 100% (243/243), respectively. Oesophageal injury was more common in patients with spontaneous pneumomediastinum and a pleural effusion (5/11, 45.4%) than in patients with spontaneous pneumomediastinum and no pleural effusion (4/159, 2.5%, p<0.001). CONCLUSION The present findings do not support routine oesophagography in patients with blunt traumatic pneumomediastinum. Conversely, a positivity rate of 4.7% in patients with spontaneous pneumomediastinum suggests oesophagography may be warranted in this population, particularly if an associated pleural effusion is present.
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Affiliation(s)
- W B Overcast
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 University Boulevard, Indianapolis, IN 46202, USA.
| | - C Taylor
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 University Boulevard, Indianapolis, IN 46202, USA
| | - A E Capps
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 University Boulevard, Indianapolis, IN 46202, USA
| | - S D Steenburg
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 University Boulevard, Indianapolis, IN 46202, USA
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17
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The Use of Enteric Contrast in the Emergency Setting. Radiol Clin North Am 2023; 61:37-51. [PMID: 36336390 DOI: 10.1016/j.rcl.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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18
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Spontaneous pneumomediastinum and subcutaneous emphysema after masturbation. Radiol Case Rep 2022; 17:1722-1726. [PMID: 35345564 PMCID: PMC8956920 DOI: 10.1016/j.radcr.2022.02.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 12/03/2022] Open
Abstract
Spontaneous pneumomediastinum is a rare condition that mostly affects young men and generally follows a benign and self-limiting course. In contrast to secondary pneumomediastinum, which is caused by trauma, iatrogenic intervention or esophageal perforation, spontaneous pneumomediastinum is triggered by violent coughing, excessive vomiting, strenuous physical exercise or Valsalva maneuver. It results from an abrupt increase in intrathoracic pressure leading to alveolar rupture and air leak along the tracheobronchial tree into the mediastinal cavity. Extended spontaneous pneumomediastinum goes along with subcutaneous emphysema of the chest, neck or head. We present a case of a healthy young man who developed pneumomediastinum and profound subcutaneous emphysema with onset during masturbation. Since there is no literature on spontaneous pneumomediastinum associated with autoerotic experiences, we consider our case an unusual presentation of this entity.
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19
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Computed Tomography Imaging of Iatrogenic Esophageal Injuries. J Comput Assist Tomogr 2022; 46:355-362. [PMID: 35297793 DOI: 10.1097/rct.0000000000001283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Knowledge of iatrogenic esophageal injuries is important given the variety of etiologies, including medical instrumentation (eg, endoscopes), radiotherapy, and anticoagulation. The clinical presentation and imaging findings of esophageal injuries depend on the mechanism and location of the injury. Imaging modalities commonly used for the evaluation of esophageal injuries include esophagram and computed tomography. Esophageal injuries should be considered in patients with acute chest symptoms. Recognizing an unsuspected esophageal injury on imaging can be critical to reaching the correct diagnosis given their nonspecific symptomatology. This review article highlights various iatrogenic esophageal injuries and their appearance on computed tomography imaging.
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20
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Seghers VJ, Kan JH, Somcio R, Sher AC, Paul Guillerman R, Sammer MBK. CT imaging of esophageal foreign bodies in children: a pictorial essay. Jpn J Radiol 2022; 40:262-270. [PMID: 34661860 DOI: 10.1007/s11604-021-01201-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/21/2021] [Indexed: 11/26/2022]
Abstract
Foreign body (FB) ingestion is common in children, particularly from 6 months to 3 years of age. As young children may be unable to provide a clinical history and the ingestion is often unwitnessed, imaging plays an important role in diagnosis, predicting outcomes and detecting complications that require surgical intervention. Since 2015, our institution's diagnostic algorithm for suspected airway foreign bodies has included a noncontrast airway FB CT (FB-CT) with the z-axis coverage spanning from the larynx to the proximal segmental bronchi of the lower lung zones. The effective dose of radiation from this FB-CT airway protocol is typically less than 1 mSv, compared to an effective dose of just under 1 mSv to up to 3 mSv for a fluoroscopic esophagram in children under 10 years of age and 1-3 mSv for a routine pediatric CT chest. In using the FB-CT airway protocol at our institution, we observed that esophageal rather than airway FBs were sometimes encountered on these exams. However, the confidence among radiologists for definitively diagnosing an esophageal foreign body on noncontrast CT was variable. Consequently, we created a teaching module of positive cases for our group of 21 pediatric body radiologists to increase their diagnostic confidence. This pictorial essay illustrates our institutional experience and can help others to confidently diagnose esophageal foreign bodies using a dedicated CT foreign body imaging protocol. At a similar radiation dose to a fluoroscopic esophagram, CT provides the additional advantage of an expedited diagnosis without the need for a radiologist on site.
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Affiliation(s)
- Victor J Seghers
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA.
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA.
| | - J Herman Kan
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Ray Somcio
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Andrew C Sher
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - R Paul Guillerman
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Marla B K Sammer
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
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21
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High risk and low prevalence diseases: Esophageal perforation. Am J Emerg Med 2021; 53:29-36. [PMID: 34971919 DOI: 10.1016/j.ajem.2021.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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22
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Morgan CT, Maloney JD, Decamp MM, McCarthy DP. A narrative review of primary spontaneous pneumomediastinum: a poorly understood and resource-intensive problem. J Thorac Dis 2021; 13:3721-3730. [PMID: 34277063 PMCID: PMC8264673 DOI: 10.21037/jtd-21-193] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/09/2021] [Indexed: 11/06/2022]
Abstract
Primary spontaneous pneumomediastinum (PSPM) is a benign self-limited condition that can be difficult to discriminate from esophageal perforation. This may trigger costly work-up, transfers and hospital admissions. To better understand this diagnostic dilemma and current management, we undertook the most comprehensive and up to date review of PSPM. The PubMed database was searched using the MeSH term "Mediastinal Emphysema"[Mesh], to identify randomized controlled trials, meta-analyses and case series (including 10 or more patients) relevant to the clinical presentation and management of patients with PSPM. There were no relevant randomized controlled trials or meta-analyses. Nineteen case series met our criteria, including a total of 535 patients. The average mean age was 23 years with a 3:1 male predominance. Chest pain was the most common symptom, found in 70.9% of the patients. Dyspnea and neck pain were the second and third most common symptoms, found in 43.4% and 32% of the patients, respectively. Subcutaneous emphysema was the most common sign (54.2%). Common histories included smoking (29.6%), cough (27.7%), asthma (25.9%), physical exertion (21.1%) and recent retching or emesis (13%). Nearly all patients (96.9%) underwent chest X-ray (CXR). Other diagnostic studies included computed tomography (65%) and esophagram (35.6%). Invasive studies were common, with 13% of patients undergoing esophagogastroduodenoscopy and 14.6% undergoing bronchoscopy. The rate of hospital admission was 86.5%, with an average length of stay of 4.4 days. No deaths were reported. Notably, we identified a dearth of information regarding the vitals, laboratory values and imaging findings specific to patients presenting with PSPM. We conclude that PSPM is a benign clinical entity that continues to present a resource-intensive diagnostic challenge and that data on the vitals, labs, and imaging findings specific to PSPM patients is scant. An improved understanding of these factors may lead to more efficient diagnosis and management of these patients.
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Affiliation(s)
- Clinton T Morgan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - James D Maloney
- Division of Cardiothoracic Surgery, Clinics Department of Surgery, University of Wisconsin Hospitals, Madison WI, USA
| | - Malcolm M Decamp
- Division of Cardiothoracic Surgery, Clinics Department of Surgery, University of Wisconsin Hospitals, Madison WI, USA
| | - Daniel P McCarthy
- Division of Cardiothoracic Surgery, Clinics Department of Surgery, University of Wisconsin Hospitals, Madison WI, USA
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23
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Sammer MBK, Kan JH, Somcio R, Sher AC, Hansen CM, Pahlka RB, Guillerman RP, Seghers VJ. Chest CT for the Diagnosis of Pediatric Esophageal Foreign Bodies. Curr Probl Diagn Radiol 2021; 50:566-570. [PMID: 33745769 DOI: 10.1067/j.cpradiol.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/04/2021] [Indexed: 01/08/2023]
Abstract
Foreign body ingestion is a common problem in children. Radiography is the mainstay of imaging, but many radiolucent items go undetected without further imaging by fluoroscopic esophagram. While studies in adults support the use of computed tomography (CT) for esophageal foreign body ingestion, CT has historically not been used in children given the typically higher radiation doses on CT compared with fluoroscopy. In distinction to an esophagram, CT does not require oral contrast nor presence of an onsite radiologist and can be interpreted remotely. At our institution, a dedicated CT protocol has been used for airway foreign bodies since 2015. Given the advantages of CT over esophagram, we retrospectively reviewed institutional radiation dose data from 2017 to 2020 for esophagrams, airway foreign body CT (FB-CT), and routine CT Chest to compare effective doses for each modality. For ages 1+ years, effective dose was lowest using the FB-CT protocol; esophagram mean dose showed the most variability, and was over double the dose of FB-CT for ages 5+ years. Routine CT chest doses were uniformly highest across all age ranges. Given these findings, we instituted a CT foreign body imaging protocol as the first-line imaging modality for radiolucent esophageal foreign body at our institution.
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Affiliation(s)
- Marla B K Sammer
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - J Herman Kan
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Ray Somcio
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Andrew C Sher
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Carly M Hansen
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX
| | - R Benton Pahlka
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX
| | - R Paul Guillerman
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX
| | - Victor J Seghers
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston TX.; Department of Radiology, Baylor College of Medicine, Houston TX..
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24
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Norton-Gregory AA, Kulkarni NM, O'Connor SD, Budovec JJ, Zorn AP, Desouches SL. CT Esophagography for Evaluation of Esophageal Perforation. Radiographics 2021; 41:447-461. [PMID: 33577418 DOI: 10.1148/rg.2021200132] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Ashley A Norton-Gregory
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
| | - Naveen M Kulkarni
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
| | - Stacy D O'Connor
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
| | - Joseph J Budovec
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
| | - Adam P Zorn
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
| | - Stephane L Desouches
- From the Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
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25
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Editor's Notebook: September 2020. AJR Am J Roentgenol 2020; 215:521-522. [DOI: 10.2214/ajr.20.23998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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