Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
Medical Image of the Week: Dobhoff Tube Placement with Roux-En-Y Gastric Bypass
Figure 1. Abdominal X-ray after Dobhoff tube (DHT) placement to confirm accurate positioning. The distal tip of the feeding tube is in a loop of jejunum in patient status post gastrojejunostomy.
Figure 2. Gastrointestinal anatomy before and after Roux-en-Y gastric bypass procedure.
Roux-en-Y gastric bypass is one of the most commonly performed bariatric operations in the United States. It involves partitioning a small gastric pouch off the proximal stomach and attaching that pouch directly to the intestine, thereby bypassing the large remainder of the stomach (1,2). Placing a Dobhoff tube (DHT) and confirming its placement can be challenging due to the change in anatomy after the procedure. Here, we have a 65-year-old woman who presented to the hospital with acute encephalopathy and acute hypoxic respiratory failure due to multifocal pneumonia requiring intubation and prolonged ICU stay. A DHT was inserted after intubation for feeding purposes. An abdominal X-ray was obtained to confirm placement of the DHT (Figure 1). Normally the DHT tip should be placed in the 2nd to 3rd portion of the duodenum and would create a C-shaped tracing on the X-ray. However, in our patient who had history of Roux-en-Y, the DHT bypassed the duodenum and went straight down from the stomach to the jejunum as illustrated in Figure 1. It is important to be aware of this change in anatomy in patients who had a Roux-en-Y gastric bypass surgery in order to confirm accurate placement of DHT.
Hasan Ali1 MD, Huthayfa Ateeli2 MBBS, Bhupinder Natt2 MD FACP, and Sachin Chaudhary2 MD.
1Department of Medicine, Division of Internal Medicine and 2Division of Pulmonary, Critical Care, Sleep and Allergy
University of Arizona College of Medicine
Tucson, AZ USA
References
- Smoot TM, Xu P, Hilsenrath P, Kuppersmith NC, Singh KP. Gastric bypass surgery in the United States, 1998–2002. Am J Public Health. 2006;96(7):1187–9. [CrossRef] [PubMed]
- Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294(15):1909–17. [CrossRef] [PubMed]
Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: Dobhoff tube placement with Roux-en-Y gastric bypass. Southwest J Pulm Crit Care. 2018;16(4):226-7. doi: https://doi.org/10.13175/swjpcc045-18 PDF
Medical Image of the Week: Abdominal Hematoma
Figure 1. Contrast-enhanced CT abdomen/pelvis showing A) coronal and B) sagittal views of a LLQ hematoma (blue braces) with active contrast extravasation (red arrow). Lines represent the level of respective axial images. C-F) Axial images demonstrating the hematoma within and expanding the rectus abdominis sheath (blue braces) as well as active contrast leak (red arrow).
Figure 2. A) Arteriogram demonstrating the large hematoma (solid arrow) with active extravasation of contrast from the inferior epigastric artery (arrowhead) arising from the external iliac artery (empty arrow). B) Coils in the inferior epigastric artery (arrow) block flow to the hematoma.
A 59 year-old man presented to clinic with acute-on-chronic non-productive cough along with sore throat and myalgias for 2 weeks and lower left quadrant (LLQ) abdominal pain for 2-3 days. He was a current smoker with history significant for COPD and mild “smoker’s cough” controlled with daily anticholinergic and as-needed beta-agonist, paroxysmal atrial fibrillation on dabigatran and diltiazem, hypertension controlled by diuretic, and a former alcoholic with hemochromatosis.
While getting an x-ray, he had a coughing fit resulting in abrupt worsening of his LLQ pain enough to inhibit ambulation. Due to his inability to walk, he came via ambulance to the emergency department, where he was mildly tachycardic with a 10cm firm, tender and ecchymotic LLQ mass.
Contrast-enhanced abdominal/pelvic CT demonstrated a large rectus abdominis hematoma. Figure 1 shows the hematoma within the rectus sheath measuring 16 cm with active contrast extravasation. The patient went directly to the interventional suite, where the left inferior epigastric artery was catheterized and subsequently embolized as shown in Figure 2.
The patient was noted to be in atrial fibrillation with rapid ventricular response (AFRVR), so was taken to the intensive care unit and placed on diltiazem drip, given digoxin and 1 unit of RBCs before his rhythm stabilized and he was transferred to the floor. His hemoglobin remained stable, and his cough and abdominal pain improved, so he was sent home off anticoagulation until follow-up with his cardiologist.
In the RE-LY trial, updated in 2010 (1), there was no difference in bleeding complications at this patient’s dosing of dabigatran compared to warfarin with INR of 2.0-3.0. However, this patient did not bleed into a critical area, require 2 units of RBCs, nor drop hemoglobin >2mg/dl, and would thus be considered having a minor bleeding event despite needing emergent embolization, losing enough blood to become tachycardic with resulting AFRVR, and getting 1 unit of RBC
Despite this particular bleeding complication, in a meta-analysis examining dabigatran vs warfarin, dabigatran uniformly was as good or better in preventing strokes with less devastating complications than warfarin (2). Additionally, although warfarin is touted as having vitamin K as its reversal agent, protein synthesis and secretion into the vasculature takes hours, similar in time to metabolically clear dabigatran (3).
In the end, after discussions about anticoagulants with the hospital team before discharge and his cardiologist thereafter, the patient elected to restart his dabigatran.
Michael Larson, M.D., Ph.D.
Banner-University Medical Center
University of Arizona
Medical Imaging Department
Tucson, AZ, USA
References
- Connolly SJ, Ezekowitz MD, Yusuf S, Reilly PA, Wallentin L; Randomized Evaluation of Long-Term Anticoagulation Therapy Investigators. Newly identified events in the RE-LY trial. N Engl J Med. 2010 Nov 4;363(19):1875-6. [CrossRef] [PubMed]
- Gómez-Outes A, Terleira-Fernández AI, Calvo-Rojas G, Suárez-Gea ML, Vargas-Castrillón E. Dabigatran, rivaroxaban, or apixaban versus warfarin in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis of subgroups. Thrombosis. 2013;2013:640723. [CrossRef] [PubMed]
- Ganetsky M, Babu KM, Salhanick SD, Brown RS, Boyer EW. Dabigatran: review of pharmacology and management of bleeding complications of this novel oral anticoagulant. J Med Toxicol. 2011 Dec;7(4):281-7. [CrossRef] [PubMed]
Cite as: Larson M. Medical image of the week: abdominal hematoma. Southwest J Pulm Crit Care. 2016:13(4): 176-8. doi: http://dx.doi.org/10.13175/swjpcc083-16 PDF