June 2022 Medical Image of the Month: A Hard Image to Swallow

Alessandra Carrillo, DO

Robert Ondracek, DO

Shil Punatar, DO

Andrew Ondracek, DO

Ravi Sundaram, DO

Department of Critical Care Medicine

Franciscan Health

Olympia Fields, Illinois USA

Figure 1. Portable chest x-ray demonstrating marked dilatation of the esophagus with food impaction and bilateral aspiration of food particles. There is also a small left pleural effusion.

Figure 2. Coronal view CT-chest/abdomen/pelvis demonstrating marked dilatation of the esophagus with food impaction seen and food particles seen in his lungs bilaterally.

Introduction

Esophageal food impactions are common occurrences in gastroenterology, however, under 20% of cases require intervention (1)  .The clinical condition of the esophagus and the consistency of food being swallowed contribute to the development of food bolus impactions, with patients having underlying esophageal pathology in most cases (2). Unfortunately, radiographic evidence is often difficult to obtain as food is radiolucent and poorly visualized on radiograph. Here, we demonstrate the risk associated with severe food impaction.

Case Presentation

An 86-year-old man with a past medical history of achalasia with laparoscopic Heller myotomy complicated by distal esophageal perforation, was admitted after presenting with complaints of chest pain and inability to tolerate a solid diet. Additionally, he suffered a 90-pound weight loss over 1 year. He was seen by speech therapy and provided with a dysphagia appropriate diet. Eight days into the patient stay, the family presented to the patient's bedside to assist in 1-to-1 feeding of the patient per their request. One hour following the completion of the patient’s feeding, a CODE BLUE was called.  The patient was unresponsive and without a pulse. PEA protocol was initiated and return of spontaneous circulation was achieved. Post intubation chest x-ray demonstrated a markedly dilated esophagus (Figures 1). Thereafter, CT chest was ordered demonstrating markedly dilated appearance of the patient’s esophagus with internal food material without as a large obstructing lesion (Figure 2). This was deemed to be the cause of the patient's cardiac arrest with concomitant aspiration. Overall, the dilatation significantly progressed from previous imaging. The patient was made NPO, transitioned to total parenteral nutrition and plans were made for a follow-up disimpaction via esophagogastroduodenoscopy (EGD). Ultimately, the patient was too unstable to pursue EGD and expired 9 days after his initial arrest.

Discussion

Through literature review, a majority of cases of food bolus impaction are self-limited. In most cases described, boluses pass on their own or with the assistance of an EGD. In most cases, underlying esophageal or motility dysfunction is known. With few case reports, food disimpaction has been assisted with cola products or nifedipine (3,4). Though trivially regarded, our case demonstrates that food bolus revel against more gruesome esophageal pathology in both presentation, prompt intervention, and adverse on outcomes.

Conclusions

We illustrate a common presentation to gastroenterologists and physicians of a food bolus impaction. Though, due to the profound radiographic presentation and severe morbidity of our clinical scenario, we hope to bring attention to the need for rapid evaluation, treatment, and consideration of adverse outcomes in patients presenting with food boluses as well as the severity and life-threatening outcomes that may preside with the previously trivially described pathology.

References

1. Yao CC, Wu IT, Lu LS, Lin SC, Liang CM, Kuo YH, Yang SC, Wu CK, Wang HM, Kuo CH, Chiou SS, Wu KL, Chiu YC, Chuah SK, Tai WC. Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract of Adults. Biomed Res Int. 2015;2015:658602. [CrossRef] [PubMed]
2. Sperry SL, Crockett SD, Miller CB, Shaheen NJ, Dellon ES. Esophageal foreign-body impactions: epidemiology, time trends, and the impact of the increasing prevalence of eosinophilic esophagitis. Gastrointest Endosc. 2011 Nov;74(5):985-91. [CrossRef] [PubMed]
3. Gelfond M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation. Gastroenterology. 1982 Nov;83(5):963-9. [PubMed]
4. Karanjia ND, Rees M. The use of Coca-Cola in the management of bolus obstruction in benign oesophageal stricture. Ann R Coll Surg Engl. 1993 Mar;75(2):94-5. [PubMed]

Cite as: Carrillo A, Ondracek R, Punatar S, Ondracek A, Sundaram R. June 2022 Medical Image of the Month: A Hard Image to Swallow. Southwest J Pulm Crit Care Sleep. 2022;24(6):93-95. doi: https://doi.org/10.13175/swjpccs022-22 PDF 

Medical Image of the Week: Zenker’s Diverticulum

Figure 1. Panel A: PA view chest x-ray shows possible cavitation with air-fluid level in the right upper lobe (arrow). Panel B: lateral view chest x-ray shows possible cavitation with air-fluid level in the right upper lobe (arrow).

Figure 2. Coronal section of the thoracic CT scan shows focal dilation of the upper thoracic esophagus which contains fluid (arrow).

Figure 3.  Endoscopic view of the upper esophagus showing the diverticulum with impacted food bolus.

A 71-year-old man with history of recurrent aspiration pneumonia and previous esophageal surgery presented to the Emergency Department with acute hypoxia and leukocytosis. Imaging, above, showed a consolidation in the RUL and on lateral view an air fluid level. This was suspicious for infection or malignancy. For the ongoing concern for possible esophageal pathology given previous surgery, GI was consulted and upper endoscopy performed.  He was found to have an esophageal dilation at repair site of a previous Zenker’s diverticulum filled with food.

Zenker’s Diverticulum is a defect in the muscular wall of the hypopharynx in an area known as Killian's triangle. This condition is male predominant mainly occurring in the 3^rd to 4^th decade and/or the 7^th to 8^th decade of life.  The out pouching created will accumulate food and eventually lead to high incidences of aspiration pneumonia. Treatment is usually surgical in nature and can cause vocal cord damage and even recurrence of the outpouching (1).  

Chandra Stockdall MD and Roberto Swazo MD

Department of Internal Medicine

Banner University Medical Center South Campus

Tucson, AZ USA

Reference

1. Mulder C, Van Delft F. Zenker’s diverticulum. UpToDate. May, 2017. Available at: http://www.uptodate.com/contents/zenkers-diverticulum (requires subscription, accessed 6/30/17).

Cite as: Stockdall C, Swazo R. Medical image of the week: Zenker's diverticulum. Southwest J Pulm Crit Care. 2017;15(1):15-6. doi: https://doi.org/10.13175/swjpcc075-17 PDF

Medical Image of the Week: Achalasia with Lung Abscess

Figure 1. CT coronal view showing a left lower lobe lung abscess measuring approximately 8 x 5 cm.

Figure 2. Barium swallow study showed dilated esophagus with tapering off at the lower esophageal sphincter junction, demonstrating the classic bird-beak like appearance.

Figure 3. Upper endoscopy showing diffuse whitish plaque suggestive of candidiasis likely due to chronic stasis of food.

An 80-year old woman with past medical history of high grade serous fallopian tube carcinoma presented with 2 months history of productive cough. This was associated with shortness of breath and subjective fever, chills and weight loss of 5 pounds over 2 months. She was treated with outpatient antibiotics without improvement of symptoms. Patient was afebrile on presentation, hemodynamically stable, and saturating at 99% on room air. Lung examinations revealed dullness on percussion of left lower lung field and reduced breath sounds on the same area.

Computed tomographic imaging revealed a large lung abscess on left lower lobe (Figure 1) and moderately dilated esophagus and fluid filled to the level of gastro-esophagus junction. Barium swallow study showed a classic bird-beak like appearance (Figure 2). There was no contrast that passed through the gastro-esophagus junction during the entire course of the barium study. Upper endoscopy was performed to rule out intraluminal pathology that may contribute to the obstruction which revealed a large amount of barium and retained food in the entire esophagus with diffuse whitish plaque suggestive of candidiasis and a benign appearing intrinsic mild stenosis at lower third of esophagus (Figure 3). Pneumatic dilation and botulinum toxin injection were performed and she was started on pantoprazole. She was also started on broad-spectrum antibiotics (vancomycin, cefepime, metronidazole) for the lung abscess. A chest tube was inserted under computed tomography (CT) guidance. Subsequently, cultures from the chest tube drainage grew Streptococcus intermedius. She was discharged to a skilled nursing facility with additional 3-weeks of ampicillin-sulbactam. Repeat imaging at 3-weeks showed improvement of the lung abscess.

Achalasia is a rare primary esophageal motor disorder, with incidence of approximately 1 in 100,000 people annually and prevalence of 10 in 100,000 (1). Common presentations of achalasia includes gradual dysphagia to solid and liquids, heartburn symptoms unrelieved by adequate proton pump inhibitor therapy and weight loss. Achalasia presenting with respiratory symptoms without dysphagia is rare as this disease entity is gradual and patient will normally present with different degrees of dysphagia or regurgitation of food. This case report is a good reminder that aspiration should be considered as a cause for pneumonia in the elderly. Our patient could have been aspirating for a period of time, leading to the development of a large lung abscess. Kikuchi et al. (2) demonstrated the high incidence of silent aspiration in the elderly population. A more detailed assessment by trained swallowing therapist may aid in detecting dysphagia.

Kai Rou Tey MD¹ and Naser Mahmoud MD²

¹Department of Internal Medicine University of Arizona College of Medicine- South Campus

²Department of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona College of Medicine

Tucson, AZ USA

References

1. Francis DL, Katzka DA. Achalasia: update on the disease and its treatment. Gastroenterology. 2010 Aug;139(2):369-74. [CrossRef] [PubMed]
2. Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med. 1994 Jul;150(1):251-3. [CrossRef] [PubMed]

Cite as: Tey KR, Mahmoud N. Medical image of the week: achalasia with lung abscess. Southwest J Pulm Crit Care. 2016 May;12(5):194-6. doi: http://dx.doi.org/10.13175/swjpcc025-16 PDF

Medical Image of the Week: Esophageal Cancer

Chandramohan Meenakshisundaram, MD 

Nanditha Malakkla, MD 

Saint Francis Hospital

Evanston, IL

Figure 1. Admission chest x-ray showing hyper-aerated lung fields and consolidation at the left lung base.

Figure 2. Video of selected images from thoracic CT scan in soft tissue windows showing large mediastinal mass with extravasation of contrast.

Figure 3. Views from endoscopy showing a large mass and the perforation site.

A 66-year-old Asian man with no significant past medical history was admitted with 1 week history of worsening retrosternal sharp chest pain, dyspnea on moderate exertion, and cough productive of brownish sputum. He also complained of some difficulty swallowing, decreased appetite and weight loss for the past 3 months. PPD was negative in the past. Vitals signs were significant for tachycardia and low grade fever. On physical exam he was cachectic and lung auscultation revealed bilateral scattered wheezes. Basic labs including complete blood count and comprehensive metabolic panel were unremarkable. EKG showed sinus tachycardia, serial troponin I was negative and chest x-ray revealed bilateral hyper-aerated lung fields and consolidation over the left lung base (Figure 1). He was started on antibiotics and bronchodilators. Since he continued to have chest pain and remained tachycardic, CT angiography of chest and abdomen (with IV and oral contrast) was done which revealed extravasation of contrast material into the mediastinum in the mid esophageal region representing rupture, a large mediastinal mass concerning for an abscess, and extensive infiltrates in the left lower lobe (Figure 2). During left thoracotomy, a large amount of necrotic material and phlegmon was seen in the mediastinum with adjacent area of lung necrosis which was drained and debrided. Upper GI endoscopy revealed a large mass in the mid-esophagus with perforation for which stenting was done (Figure 3). Pathology of phlegmon revealed squamous cell carcinoma with extensive necrosis. Culture of the fluid grew both viridians streptococci and anaerobes and he was started on broad spectrum antibiotics. His post-operative course was complicated and later he elected hospice care.

Reference as: Meenakshisundaram C, Malakkla N. Medical image of the week: eosphageal cancer. Southwest J Pulm Crit Care. 2014;9(5):295-6. doi: http://dx.doi.org/10.13175/swjpcc151-14 PDF