Medical Image of the Week: Esophageal Perforation

Figure 1. Axial, non-contrast CT of chest demonstrates wall thickening of the mid-thoracic esophagus with an extra-luminal focus of gas (blue arrow) in the mediastinum in addition to a small amount of right peri-esophageal fluid (red arrow).

Figure 2. Sagittal, non-contrast CT of chest demonstrates extra-luminal air posterior to the mid-thoracic esophagus (blue arrows).

A 74 year old man with a past medical history of esophageal strictures status post dilatation, coronary artery disease status post CABG, and atrial fibrillation presented to hospital with complaints of severe chest pain that began after the consumption of tortilla chips one hour prior to presentation. Electrocardiogram and cardiac enzymes were not consistent with acute coronary syndrome. Chest X-ray was consistent with a widened mediastinal silhouette. Contrast esophogram was negative for extra luminal extravasation. CT scan of the chest with oral contrast demonstrated thickening of the mid-thoracic esophagus with an extra-luminal focus of gas in the mediastinum along with fluid along the inferior aspect of the esophagus (Figures 1 and 2). These findings were concerning for esophageal perforation. The patient was taken to the operating room for endoscopy which showed micro perforation in mid-esophagus.

Esophageal perforation remains a highly morbid condition. Mortality rates are based predominantly on time of presentation and the etiology of perforation. Symptoms of esophageal perforation are non-specific and include neck or chest pain, dysphagia, odynophagia, difficulty breathing, vomiting, drooling, hematemesis, and abdominal rigidity (1) Initial diagnostic assessment includes conventional radiography, which can be normal in up to 10% of patients. Follow-up contrast esophograms are used to determine the presence and precise location of an esophageal perforation. However, false negative rates of 10% have been reported (2). CT scan of the chest or abdomen is indicated when contrast esophogram cannot be performed or all other diagnostic modalities have not been helpful in diagnosing esophageal perforation despite high clinical suspicion. Extra-luminal air in the mediastinum or surrounding the esophagus is the most reliable sign and when taken in conjunction with the clinical presentation, has 92% accuracy. Other common findings include obliteration of fat planes in the mediastinum resulting from inflammation, peri-esophageal or mediastinal fluid (92% accuracy), esophageal thickening, pleural effusions, extravasation of oral contrast material into the peri-esophageal tissues, and a tract at the site of the tear (3).

Jawad Bilal MD, David Testa MD, Irbaz bin Riaz MD and Ryan Nahapetian MD MPH

University of Arizona

Tucson, AZ

References

1. Aronberg RM, Punekar SR, Adam SI, Judson BL, Mehra S, Yarbrough WG. Esophageal perforation caused by edible foreign bodies: A systematic review of the literature. Laryngoscope. 2015;125(2):371-8. [CrossRef] [PubMed]
2. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. 1986;42(3):235-9. [CrossRef] [PubMed]
3. Lee S, Mergo PJ, Ros PR. The leaking esophagus: CT patterns of esophageal rupture, perforation, and fistulization. Crit Rev Diagn Imaging. 1996;37(6):461-90. [PubMed] 

Reference as: Bilal J, Testa D, Riaz I, Nahapetian R. Medical image of the week: eosphageal perforation. Southwest J Pulm Crit Care. 2015;10(4):201-2. doi: http://dx.doi.org/10.13175/swjpcc033-15 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