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 2^nd to 3^rd 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

1. 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]
2. 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: DISH with OPLL and C3 Fracture

Figure 1. CT imaging showing severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable cervical spinal fracture. A and C: Sagittal images showing “flowing” anterior osteophytes (red arrow) characteristic of DISH as well as OPLL (black arrow). A: An unstable C3 fracture with posterior subluxation resulting in >50% osseous narrowing of the spinal canal is present. B: Soft tissue window and D: bone algorithm and bone window showing severe narrowing of the spinal canal. B and D are at the level of the white line seen on A.

Figure 2. Occiput to C6 posterior fusion with C1-C6 laminectomies.

A 54-year old man presented after a fall while intoxicated, during which a small frontal sinus fracture was sustained. Upon initial presentation, he was minimally responsive and eventually developed cardiopulmonary arrest. After intubation and return of circulation, he was immediately transferred from Mexico to an Arizona tertiary medical center, where his head and cervical spine CT showed severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable C3 fracture with posterior subluxation and severe canal narrowing (Figure 1).

DISH, also known as Forestier disease, is a skeletal disorder, primarily affecting middle-aged and elderly patients, in which there is a buildup of calcified osseous tissue occurring in the ligaments of the spine. DISH is associated with ossifications occurring specifically in the posterior longitudinal ligaments of the spine, referred to as DISH with OPLL, which is twice as common in men compared to women (1).

DISH with OPLL is often asymptomatic in the early stages of the disease, and thus is often diagnosed either incidentally or after the disease has progressed significantly. Patients with this disease are predisposed to increased risk of spinal fractures, even with relatively minor trauma. Additionally, as DISH with OPLL can result in decreased range of motion, difficult intubation can result, possibly resulting in altered approaches to typical intubation procedures (1).

While the patient likely fractured his spine from the initial fall, it was not determined whether the intubation procedure could have contributed to the spinal fracture subluxation and/or spinal cord injury. Regardless, the patient underwent an occiput to C6 posterior fusion with C1-C6 laminectomies (Figure 2) and will receive long term neurologic rehabilitation.

Stephanie R. Fletcher, BSHS¹ and Michael Craig Larson, MD, PhD²

¹College of Pharmacy and ²Department of Radiology

University of Arizona

Tucson, AZ USA

Reference

1. Baxi V, Gaiwal S. Diffuse idiopathic skeletal hyperostosis of cervical spine - An unusual cause of difficult flexible fiber optic intubation. Saudi J Anaesth. 2010 Jan;4(1):17-9. [CrossRef] [PubMed]

Cite as: Fletcher SR, Larson MC. Medical image of the week: DISH with OPLL and C3 fracture. Southwest J Pulm Crit Care. 2017;14(4):157-8. doi: https://doi.org/10.13175/swjpcc041-17 PDF 

Medical Image of the week: Chronic Pulmonary Histoplasmosis

Figure 1. Chest radiography showing upper lobe fibrosis and cavitation secondary to chronic histoplasmosis.

Histoplasmosis is endemic to the Midwest US and commonly causes an acute infection that presents as a subacute pneumonia.  In patients with underlying lung disease, particularly COPD, a subacute pneumonia can evolve into chronic pulmonary histoplasmosis and is characterized by persistent or recurrent pulmonary symptoms, progressive lung infiltrates, fibrosis, and cavitation. Upper lobe infiltrates and cavities are characteristic, resembling the findings in tuberculosis (Figure 1). Progression is manifested by cavity enlargement, increased fibrosis and bronchopleural fistulae.  Misdiagnosis delays therapy and can be catastrophic.  Histoplasmosis titers and sputum cultures are useful tests.  Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy for culture may be needed when diagnosis remains elusive.

Kenneth S. Knox, MD¹ and Veronica A. Arteaga, MD²

¹Professor of Medicine

University of Arizona College of Medicine- Phoenix

Phoenix, AZ USA

²Associate Professor of Medicine

Medical Imaging

University of Arizona College of Medicine- Tucson

Tucson, AZ USA

Cite as: Knox KS, Artega VA. Medical image of the week: chronic pulmonary histoplasmosis. Southwest J Pulm Crit Care. 2017;14(3):88. doi: https://doi.org/10.13175/swjpcc022-17 PDF

Medical Image of the Week: Chilaiditi Syndrome

Figure 1. An X-ray of the chest showing a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (arrow).

Figure 2. CT scan of the chest showing gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (arrow).

X-ray evidence of air under right hemi-diaphragm in proper clinical context is almost a definitive sign of gastrointestinal tract perforation except in an extremely rare clinical entity called "Chilaiditi Syndrome". We present this unique image and clinical scenario to expand on physician`s knowledge to identify this rare clinical syndrome and to help distinguish it from a dreaded condition like gastrointestinal perforation.

An 81-year-old man with multiple co-morbidities was admitted to the intensive care unit with a diagnosis of acute hypoxic respiratory failure. An X-ray of the chest showed a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (Figure 1). Due to radiological concern of gastrointestinal perforation, an emergent CT scan was performed to rule out perforation. CT scan revealed gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (Figure 2). The patient had no gastro-intestinal tract symptoms and no pathological signs were specifically identified on clinical examination; a diagnosis of the Chilaiditi Syndrome was made. Chilaiditi Syndrome occurs due to interposition of a loop of large intestine in between the liver and the diaphragm. The incidence of Chilaiditi Syndrome is 0.025 to 0.28% and occurs because of congenital anatomical variations of falciform ligament (1). It can also be due to functional abnormalities such as constipation, aerophagia, cirrhosis, paralysis of the diaphragm, chronic lung disease which can cause enlargement of the lower thoracic cavity, obesity, and processes which increase intra-abdominal pressure (1,2). Initial management includes conservative therapy - Bed rest, intravenous fluid hydration, and bowel decompression. Surgical options can be considered (3).

Priyanka Makkar, M.D.¹, Rishabh Mishra, M.D.¹, and Shivanck Upadhyay, M.D.²

¹Internal Medicine department, St. Barnabas Hospital, Bronx, New York

²Department of Pulmonary Critical Care Medicine, St. Barnabas Hospital, Bronx, New York

References

1. Alva S, Shetty-Alva N, Longo WE. Image of the month. Chilaiditi sign or syndrome. Arch Surg. 2008 Jan;143(1):93-4. [CrossRef] [PubMed]
2. Fisher AA, Davis MW. An elderly man with chest pain, shortness of breath, and constipation. Postgrad Med J. 2003 Mar;79(929):180, 183-4. [CrossRef] [PubMed]
3. Blevins WA, Cafasso DE, Fernandez M, Edwards MJ.Minimally invasive colopexy for pediatric Chilaiditi syndrome. J Pediatr Surg. 2011 Mar;46(3):e33-5. [CrossRef] [PubMed]

Cite as: Makkar P, Mishra R, Upadhyay S. Medical image of the week: Chilaiditi syndrome. Southwest J Pulm Crit Care. 2016;13(4):179-80. doi: http://dx.doi.org/10.13175/swjpcc077-16 PDF