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Long Case One

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indianradiologists

A patient presented with dyspnea following an upper GI endoscopy. Imaging found pneumomediastinum, subcutaneous emphysema, a right pleural effusion, and free intraperitoneal air. This was diagnosed as an iatrogenic esophageal perforation during the endoscopy, with defects in the upper third of the esophagus wall allowing air to dissect into the mediastinum and peritoneum. A non-ionic contrast would be used instead of barium for follow-up exams due to risk of mediastinal fibrosis from the perforation.

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Dyspnoea following upper GI endoscopy for esophageal stricture
Dyspnoea following upper GI endoscopy for esophageal stricture What are the findings?
Findings Pneumomediastinum with subcutaneous surgical emphysema Right sided mild pleural effusion Emphysematous esophagus walls with focal defect in posterior wall of its upper third. Intramural contrast collection seen in continuity of this defect Free intraperitoneal air Diagnosis : Iatrogenic esophageal perforation with pneumomediastinum , surgical emphysema , right pleural effusion and free intraperitoneal air Q. What may be the cause of intraperitoneal air ? Air dissecting along length of esophageal wall into peritoneal cavity Q. What concentration of oral barium will you give in this patient for barium swallow examination ? Barium swallow is usually not done - due to risk of mediastinal fibrosis. A nonionic contrast media is rather used.
Q. What are the causes of pneumomediastinum ? 1. Lung tear: Spontaneous the most common cause, may follow coughing and strenuous exercise Chest trauma, Asthma, artificial ventilation, child birth related to repeated valsalva maneuver, foreign body aspiration 2. Iatrogenic perforation of esophagus, trachea or bronchus 3. Boerhaaves syndrome due to retching and vomiting with perforation, usually left posterolateral wall of distal esophagus 4. Perforation of hollow abdominal viscus- with extension of gas via retroperitoneal space Suggested further reading: Causes of pneumoperitoneum X Ray signs of pneumomediastinum and pneumoperitoneum Note : Iatrogenic esophageal perf. are more common in upper third of esophagus

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Long Case One

  • 1. Dyspnoea following upper GI endoscopy for esophageal stricture
  • 2. Dyspnoea following upper GI endoscopy for esophageal stricture What are the findings?
  • 3. Findings Pneumomediastinum with subcutaneous surgical emphysema Right sided mild pleural effusion Emphysematous esophagus walls with focal defect in posterior wall of its upper third. Intramural contrast collection seen in continuity of this defect Free intraperitoneal air Diagnosis : Iatrogenic esophageal perforation with pneumomediastinum , surgical emphysema , right pleural effusion and free intraperitoneal air Q. What may be the cause of intraperitoneal air ? Air dissecting along length of esophageal wall into peritoneal cavity Q. What concentration of oral barium will you give in this patient for barium swallow examination ? Barium swallow is usually not done - due to risk of mediastinal fibrosis. A nonionic contrast media is rather used.
  • 4. Q. What are the causes of pneumomediastinum ? 1. Lung tear: Spontaneous the most common cause, may follow coughing and strenuous exercise Chest trauma, Asthma, artificial ventilation, child birth related to repeated valsalva maneuver, foreign body aspiration 2. Iatrogenic perforation of esophagus, trachea or bronchus 3. Boerhaaves syndrome due to retching and vomiting with perforation, usually left posterolateral wall of distal esophagus 4. Perforation of hollow abdominal viscus- with extension of gas via retroperitoneal space Suggested further reading: Causes of pneumoperitoneum X Ray signs of pneumomediastinum and pneumoperitoneum Note : Iatrogenic esophageal perf. are more common in upper third of esophagus