(Radiographics. 2002;22:S247-S258.)
© RSNA, 2002
Thoracic Complications of Esophageal Disorders1
Ana Giménez, MD,
Tomás Franquet, MD,
Jeremy J. Erasmus, MD,
Santiago Martínez, MD and
Pilar Estrada, MD
1 From the Department of Radiology, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Avda Sant Antoni M. Claret 167, 08025 Barcelona, Spain (A.G., T.F., S.M., P.E.); and the Department of Radiology, M. D. Anderson Cancer Center, Houston, Tex (J.J.E.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 22, 2002; revision requested March 27 and received May 29; accepted June 14. Address correspondence to A.G. (e-mail: agimenez@hsp.santpau.es).
 |
Abstract
|
|---|
Abnormalities of the esophagus are common, and complications associated with these disorders and diseases can involve the mediastinum, tracheobronchial tree, and lungs. The most common complications include mediastinitis secondary to esophageal perforation or postoperative anastomotic leak, or both; empyema due to fistula formation; and aspiration pneumonia. The authors reviewed the radiologic appearances of those and other common thoracic complications associated with esophageal disorders to facilitate early detection, diagnosis, and management. Computed tomographic (CT) findings of acute mediastinitis secondary to esophageal perforation may include esophageal thickening, extraluminal gas, pleural effusion, single or multiple abscesses, and extraluminal contrast medium. The radiologic manifestations of pneumonia secondary to tracheoesophageal fistula are variable, depending on the spread and severity of the aspiration. The most common radiographic pattern is that of bronchopneumonia with scattered air-space opacities. CT has been regarded as the imaging modality of choice for the evaluation of suspected esophagopleural fistula, because the site of communication between the pleural space and the esophagus can often be seen. An awareness of the radiologic manifestations of these complications is thus required to facilitate early diagnosis.
© RSNA, 2002
Index Terms: Empyema, 6.76 • Esophagus, perforation, 71.41 • Fistula, gastrointestinal tract, 71.41 • Lung, aspiration, 60.214 • Lung, infection, 60.20 • Mediastinitis, 67.272
|
Introduction
|
|---|
The wide range of esophageal disorders includes infectious and inflammatory processes, trauma and perforation, and benign and malignant neoplasms. Thoracic and pulmonary complications can occur secondary to these disorders and often are associated with high morbidity and mortality. Such complications can be categorized as (a) mediastinal complications due to blunt and penetrating trauma, spontaneous perforation, malignancy, foreign bodies, instrumentation, and caustic injury; (b) tracheobronchial complications, including tracheoesophageal fistulas, either congenital or acquired; (c) pleural complications, including esophagopleural fistulas; and (d) lung complications, including aspiration bronchiolitis, bronchopneumonia, and obliterative bronchiolitis. The most common complications include mediastinitis secondary to esophageal perforation or postoperative anastomotic leak, or both; empyema due to fistula formation; and aspiration pneumonia. Because an understanding of the clinical and radiologic manifestations of these complications can facilitate early detection, diagnosis, and management, this article reviews the more common thoracic and pulmonary complications associated with esophageal disorders.
|
Normal Esophageal Anatomy and Function
|
|---|
The esophagus is a muscular tube 20–24 cm long that connects the pharynx to the stomach and is divisible into three segments: cervical, thoracic, and abdominal. The cervical portion of the esophagus lies near the midline, posterior to the trachea and anterior to the vertebrae. Because this portion is relatively narrow, traumatic perforation at this level is common, especially in the region of the upper esophageal sphincter, where there are areas of muscular weakness. At the thoracic inlet, the esophagus lies posterior and slightly to the left of the trachea. Throughout its course in the mediastinum, the esophagus is intimately related to the posterior surface of the left primary bronchus and adjacent to the left lung, aorta, and heart. The upper third of the thoracic esophagus has an intimate relationship with the posterior surface of the trachea, whereas the lower third is closely related to the aorta and the left atrium. One anatomic point of importance is the esophageal contact with pleura for a considerable distance on the right side, whereas on the left side, the aorta is interposed between the esophagus and the pleura except for a short distance just above the diaphragm. Consequently, processes that involve the middle part of the esophagus can spread to involve the right pleura more easily than the left. The thoracic portion of the esophagus ends where the esophagus passes through the diaphragm anterior to the aorta, to the left of the midline.
|
Techniques for Examination of Esophageal Disorders
|
|---|
Although some of the mediastinal lines and stripes seen on chest radiographs are formed by esophageal-lung interfaces, conventional chest radiography has a limited role in the assessment of esophageal diseases. Barium esophagography is considered the initial method of choice in the imaging evaluation of suspected uncomplicated esophageal processes. When esophageal perforation is clinically suspected, the examination should initially be performed with water-soluble contrast agents such as Gastrografin (meglumine diatrizoate), which is rapidly absorbed from the mediastinum. Conversely, meglumine diatrizoate should not be allowed to enter the tracheobronchial tree, as this hyperosmolar agent may draw fluid into the lungs, causing pulmonary edema.
Whereas computed tomography (CT) has a complementary role in the evaluation of esophageal disorders, CT is primarily used for preoperative staging of esophageal carcinoma, as well as for the assessment of thoracic complications related to esophageal perforation.
|
Mediastinal Complications
|
|---|
Esophageal Perforation
Esophageal perforation is an uncommon and life-threatening event that occurs more frequently in association with the use of endoscopic instruments and surgical thoracic procedures. This complication has been reported in about one per 1,000 patients who undergo endoscopic examinations. Blandergroen et al found that esophageal perforation was iatrogenic in 55% of 114 cases of esophageal rupture; in the remaining cases, 15% of the perforations were spontaneous, 14% were due to a foreign body (Fig 1), and 10% were traumatic (blunt or penetrating injury) (1). Sixty-three patients had underlying esophageal disease, such as esophageal neoplasm (1–10).
View larger version (90K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1a. Multiple esophageal perforation due to chicken bone impaction in a 75-year-old woman with sensation of a foreign body, dysphagia, odynophagia, and drooling. (a) Barium esophagogram reveals a double esophageal tear. (b) Photograph of an autopsy specimen shows chicken bone impaction and perforation to the mediastinum. L = left perforation, R = right perforation.
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1b. Multiple esophageal perforation due to chicken bone impaction in a 75-year-old woman with sensation of a foreign body, dysphagia, odynophagia, and drooling. (a) Barium esophagogram reveals a double esophageal tear. (b) Photograph of an autopsy specimen shows chicken bone impaction and perforation to the mediastinum. L = left perforation, R = right perforation.
|
|
A distinctive clinical picture results from a spontaneous rupture of the esophagus due to a violent vomiting episode (Boerhaave syndrome). This rare disease affects approximately one in 6,000 patients. Rupture is typically posterior, near the left diaphragmatic crus (Fig 2) (11–13).
View larger version (108K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Spontaneous perforation of the esophagus (Boerhaave syndrome) with mediastinal abscess in a 58-year-old man with burning substernal pain. (a) Esophagogram shows a massive leak of barium to the mediastinum. (b) CT scan shows a periesophageal mediastinal abscess (arrow) with bilateral pleural effusion. A tube is present in the right side of the chest. A right paracardiac collection is also seen (*).
|
|
View larger version (113K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Spontaneous perforation of the esophagus (Boerhaave syndrome) with mediastinal abscess in a 58-year-old man with burning substernal pain. (a) Esophagogram shows a massive leak of barium to the mediastinum. (b) CT scan shows a periesophageal mediastinal abscess (arrow) with bilateral pleural effusion. A tube is present in the right side of the chest. A right paracardiac collection is also seen (*).
|
|
Clinically, esophageal perforation must be suspected on the basis of the history in association with vomiting, chest pain, fever, and subcutaneous emphysema (14,15). Chest radiographic detection of esophageal perforation is reliant on the presence of indirect radiologic signs, including pneumomediastinum, left-sided pneumothorax, and pleural effusion. Although results of chest radiography can be normal, pneumomediastinum typically is manifest radiologically as visualization of the pleura as a white line adjacent to the mediastinum, linear streaks of radiolucency in the mediastinum and cervical soft tissues, focal retrosternal air collections, linear extrapleural air collection outlining the diaphragm ("continuous diaphragm"), and a focal, sharply marginated area of radiolucency in a paraspinal location on the left side immediately above the diaphragm ("V sign" of Naclerio) (Fig 3) (16). Although contrast-enhanced esophagography has been the standard technique for diagnosis of esophageal perforation, up to 10% of patients can have a false-negative result of barium esophagography (14,15). However, extravasation of oral contrast material into the mediastinum is an unequivocal sign of perforation. When these classic radiographic signs are equivocal, CT may be used as a complementary imaging method.
View larger version (116K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3. Traumatic esophageal rupture with pneumomediastinum in a 53-year-old man. Contrast-enhanced esophagogram shows esophageal rupture with a right-sided paraesophageal collection of meglumine diatrizoate (arrows). Linear streaks of mediastinal air and extrapleural air that outline the diaphragm ("continuous diaphragm") are also shown (arrowheads).
|
|
Acute Mediastinitis and Mediastinal Abscess
The mediastinum is rarely the site of primary hematogenous infection, but occasionally, acute mediastinitis is caused by esophageal perforation, rupture of the tracheobronchial tree, or extension of infection from neighboring structures. Fulminant mediastinitis and mediastinal abscess formation have been reported to occur in 1% of patients with esophageal perforation (15). Early diagnosis is mandatory for the prevention of these complications and improvement of patient survival. Unfortunately, the diagnosis is often delayed because patients can have atypical symptoms that mimic myocardial infarction, aortic dissection, and pulmonary thromboembolism.
Conventional chest radiography may show the widening and loss of the normal contours of the upper mediastinum, within which there may also be visible signs of free mediastinal air collections (pneumomediastinum). In these cases, esophagography may show the escape of contrast material into the mediastinal tissues or into the pleural cavity.
CT can be helpful in the assessment of suspected acute mediastinitis and mediastinal abscess. CT also provides an excellent evaluation of the extent of mediastinal soft-tissue infiltration and can be helpful in guiding percutaneous aspiration and drainage of mediastinal abscesses. CT findings of acute mediastinitis secondary to esophageal perforation may include esophageal thickening, extraluminal gas, pleural effusion, single or multiple abscesses, and extraluminal contrast medium (15).
|
Tracheobronchial Complications
|
|---|
Congenital Tracheoesophageal Fistula
Several congenital variations in tracheal development may occur within the spectrum of failure of tracheoesophageal differentiation from the primitive foregut (17–19) (Fig 4). Esophageal atresia associated with a distal tracheoesophageal fistula is by far the most common type of defect, occurring in 87% of affected infants. The development of recurrent pneumonias during the neonatal period is often the result of direct lung contamination from a congenital tracheoesophageal fistula (18). Acute episodes of aspiration are symptomatic, and patients usually present with symptoms of pneumonia or respiratory distress, or both. The radiologic manifestations are variable, depending on the spread and severity of the aspiration. The most common radiographic pattern is that of bronchopneumonia with scattered air-space opacities (20). If recurrent aspiration or pneumonia is thought to be due to a tracheoesophageal fistula, the diagnosis is usually confirmed with barium esophagography (Fig 5) (20).
View larger version (46K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4. Classification scheme for esophageal atresia and tracheoesophageal fistula. Drawings show atresia with upper fistula (A), atresia with both lower and upper fistulas (B), atresia with lower fistula (C), and tracheoesophageal fistula with no atresia (D). (Modified, with permission, from reference 9.)
|
|
View larger version (131K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5. Respiratory difficulty after feedings in a 3-day-old boy. Barium esophagogram clearly shows an H-shaped fistula between the trachea and the middle segment of the esophagus (arrowhead). Barium is filling the bronchi of the right lower lobe (arrows).
|
|
Acquired Esophagorespiratory Fistula
In adults, esophageal fistulas are usually acquired lesions. They can occur as a complication of intrathoracic malignancies (60%), prolonged tracheal intubation, esophageal instrumentation (including endoscopy and esophageal tube placement), and infection or trauma (21,22). Formation of a fistula between the esophagus and the lung, bronchi, trachea, or some combination is exceedingly rare in the absence of these predisposing factors (23). Fistulas occur in 5%–10% of patients with advanced esophageal cancer (Fig 6),and the risk of fistula formation is increased if there has been prior irradiation (Fig 7) (24–26). The prognosis is extremely poor (21,27). Radiographic findings are nonspecific, and the diagnosis should be strongly suspected in any patient with a known esophageal neoplasm in whom there is recurrent pneumonia. Pulmonary consolidation is typically unilateral but may involve both lungs. Diagnosis is usually made with a fluoroscopic contrast-enhanced study. However, CT may be helpful in the diagnosis of a fistulous tract formation in those cases with normal findings at esophagography (Fig 8) (28).
View larger version (133K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6a. Advanced esophageal squamous carcinoma with tracheal invasion in a 68-year-old man. (a) Left lateral chest radiograph shows a large posterotracheal mass (*). (b) Contrast-enhanced CT scan shows an esophageal mass with tracheal invasion (arrowhead). (c) Virtual endoscopic image shows posterior invasion of the trachea (arrowheads). A = anterior, P = posterior.
|
|
View larger version (88K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6b. Advanced esophageal squamous carcinoma with tracheal invasion in a 68-year-old man. (a) Left lateral chest radiograph shows a large posterotracheal mass (*). (b) Contrast-enhanced CT scan shows an esophageal mass with tracheal invasion (arrowhead). (c) Virtual endoscopic image shows posterior invasion of the trachea (arrowheads). A = anterior, P = posterior.
|
|
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6c. Advanced esophageal squamous carcinoma with tracheal invasion in a 68-year-old man. (a) Left lateral chest radiograph shows a large posterotracheal mass (*). (b) Contrast-enhanced CT scan shows an esophageal mass with tracheal invasion (arrowhead). (c) Virtual endoscopic image shows posterior invasion of the trachea (arrowheads). A = anterior, P = posterior.
|
|
View larger version (114K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7a. Esophageal carcinoma with esophagopulmonary fistula secondary to radiation therapy in a 63-year-old man. (a) Barium esophagogram shows a large esophagopulmonary fistula. (b) CT scan also shows a large ulceration, with barium in the right upper lobe.
|
|
View larger version (110K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7b. Esophageal carcinoma with esophagopulmonary fistula secondary to radiation therapy in a 63-year-old man. (a) Barium esophagogram shows a large esophagopulmonary fistula. (b) CT scan also shows a large ulceration, with barium in the right upper lobe.
|
|
View larger version (100K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8a. Hodgkin disease (nodular sclerosis) in a 42-year-old man with esophagopulmonary and esophagomediastinal fistulas. (a) Contrast-enhanced CT scan shows a mediastinal lymphadenopathic mass with esophageal involvement and esophagomediastinal fistula. (b) Contrast-enhanced CT scan shows an esophagopulmonary fistula (arrowheads). Extensive vertebral body involvement is also shown.
|
|
View larger version (104K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8b. Hodgkin disease (nodular sclerosis) in a 42-year-old man with esophagopulmonary and esophagomediastinal fistulas. (a) Contrast-enhanced CT scan shows a mediastinal lymphadenopathic mass with esophageal involvement and esophagomediastinal fistula. (b) Contrast-enhanced CT scan shows an esophagopulmonary fistula (arrowheads). Extensive vertebral body involvement is also shown.
|
|
|
Pleural Complications
|
|---|
Because of the close anatomic relationship between the esophagus and pleura, abnormal communications or fistulas may develop between these structures owing to a variety of benign and malignant processes. Early diagnosis is important because of the life-threatening consequences of these fistulas.
Esophagopleural fistula is commonly associated with advanced esophageal carcinoma, esophageal tuberculosis, surgical procedures, endoscopic examinations, chemical injury after ingestion of corrosive substances (Fig 9), and radiation therapy. The radiographic findings that suggest the occurrence of esophagopleural fistula include air in the pleural space or hydropneumothorax, or both. CT has been regarded as the imaging modality of choice for the evaluation of suspected esophagopleural fistula. The site of communication between the pleural space and the esophagus can often be seen at CT (28).
View larger version (64K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9. Esophagopleural fistula secondary to caustic esophagitis in a 13-year-old boy who ingested concentrated sodium hydroxide. Esophagogram shows a long fistula to the left pleural space. Meglumine diatrizoate swallow shows a diffusely stenotic esophagus.
|
|
|
Pulmonary Complications
|
|---|
Barium Aspiration
The aspiration of barium is a well-recognized complication that occurs during imaging of the gastrointestinal tract (29). Several esophageal disorders may predispose to barium aspiration, including those related to recent esophageal surgery and hiatal hernia (Fig 10). The overall mortality associated with massive barium aspiration is approximately 30% and exceeds 50% in those patients with initial shock or apnea, secondary pneumonia, or acute respiratory distress syndrome (29,30).
View larger version (86K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10a. Barium aspiration in the left lower lobe. (a) Gastroesophagogram shows nodular and linear branching opacities in a bronchiolar distribution due to barium aspiration (arrowheads). A hiatal hernia is also shown. (b) Photomicrograph of an autopsy specimen shows birefringent aspirated material that corresponds to barium (*).
|
|
View larger version (195K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10b. Barium aspiration in the left lower lobe. (a) Gastroesophagogram shows nodular and linear branching opacities in a bronchiolar distribution due to barium aspiration (arrowheads). A hiatal hernia is also shown. (b) Photomicrograph of an autopsy specimen shows birefringent aspirated material that corresponds to barium (*).
|
|
Diffuse Aspiration Bronchiolitis and Aspiration Pneumonitis
Diffuse aspiration bronchiolitis is characterized by chronic inflammatory reaction to repeated aspiration of foreign particles into the bronchioles (31). Patients with esophageal conditions such as achalasia (Fig 11), Zenker diverticulum (Fig 12), or esophageal carcinoma (Fig 13) are at risk for aspiration bronchiolitis. Chest radiographic findings are nonspecific, consisting of lobar, segmental, or disseminated small nodular opacities. At high-resolution CT, aspiration bronchiolitis typically is manifest as unilateral or bilateral foci of branching areas of increased attenuation with a tree-in-bud appearance, centrilobular nodules, and poorly marginated acinar areas of increased attenuation (17).
View larger version (134K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11. Achalasia and aspiration bronchiolitis in a 62-year-old woman. High-resolution CT scan shows a markedly dilated esophagus and multiple bilateral tubular or branched filled bronchioles.
|
|
View larger version (146K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12a. Zenker diverticulum and aspiration bronchiolitis in a 68-year-old woman with cough and halitosis. (a) Posteroanterior chest radiograph shows an air-fluid level (arrowheads). (b) CT scan shows aspiration bronchiolitis in the left upper lobe with multiple filled bronchioles.
|
|
View larger version (113K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12b. Zenker diverticulum and aspiration bronchiolitis in a 68-year-old woman with cough and halitosis. (a) Posteroanterior chest radiograph shows an air-fluid level (arrowheads). (b) CT scan shows aspiration bronchiolitis in the left upper lobe with multiple filled bronchioles.
|
|
View larger version (115K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13a. Esophageal carcinoma with lung aspiration in a 58-year-old man. (a) CT scan shows polypoid carcinoma in the middle third of the esophagus (arrow). (b) CT scan (lung window) obtained at a higher level than in a shows aspiration bronchiolitis in the right upper lobe.
|
|
View larger version (118K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13b. Esophageal carcinoma with lung aspiration in a 58-year-old man. (a) CT scan shows polypoid carcinoma in the middle third of the esophagus (arrow). (b) CT scan (lung window) obtained at a higher level than in a shows aspiration bronchiolitis in the right upper lobe.
|
|
Aspiration Pneumonia and Lung Abscess
Aspiration pneumonia is a common complication of esophageal dysmotility (Fig 14). Ninety percent of aspiration pneumonias are caused by anaerobic organisms and gram-negative bacteria related to aspiration of contaminated substances from the oropharynx and gastrointestinal tract (32). Aspiration typically is manifest radiographically as bronchopneumonia with scattered heterogeneous opacities; lobar air-space consolidation is much less common. The patient’s body position plays a significant role in the anatomic distribution of aspirated material. Whereas the posterior segments of the upper lobes and the superior segments of the lower lobes are most often involved in subjects in a supine position, the posterior segments of the lower lobes are more frequently involved in erect patients. Aspiration can also occasionally result in severe necrotizing infection complicated by abscess formation (17).
View larger version (116K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14a. Polymyositis and aspiration pneumonia in a 53-year-old woman. (a) Posteroanterior chest radiograph shows bilateral alveolar infiltrates. (b) High-resolution CT scan obtained at the level of the upper lobes shows an esophageal dilatation related to esophageal dysmotility. An air-fluid level in the esophagus is also shown (arrowhead). (c) CT scan obtained at a lower level than in b shows a left upper lobe infiltrate related to aspiration pneumonia.
|
|
View larger version (134K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14b. Polymyositis and aspiration pneumonia in a 53-year-old woman. (a) Posteroanterior chest radiograph shows bilateral alveolar infiltrates. (b) High-resolution CT scan obtained at the level of the upper lobes shows an esophageal dilatation related to esophageal dysmotility. An air-fluid level in the esophagus is also shown (arrowhead). (c) CT scan obtained at a lower level than in b shows a left upper lobe infiltrate related to aspiration pneumonia.
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14c. Polymyositis and aspiration pneumonia in a 53-year-old woman. (a) Posteroanterior chest radiograph shows bilateral alveolar infiltrates. (b) High-resolution CT scan obtained at the level of the upper lobes shows an esophageal dilatation related to esophageal dysmotility. An air-fluid level in the esophagus is also shown (arrowhead). (c) CT scan obtained at a lower level than in b shows a left upper lobe infiltrate related to aspiration pneumonia.
|
|
Obliterative Bronchiolitis
Although the association of obliterative bronchiolitis and aspiration remains controversial, intermittent aspiration of microscopic amounts of gastrointestinal fluid may be a contributing factor in the pathogenesis of airway obstruction (17,33, 34). A significant number of patients with chronic bronchitis and asthma have gastroesophageal reflux (17,33,35). In these patients, thin-section CT findings include bronchial dilatation, mosaic perfusion, bronchial wall thickening, and air trapping (Fig 15) (17,35,36).
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15a. Gastric aspiration and obliterative bronchiolitis in a 68-year-old woman with achalasia. (a) Posteroanterior chest radiograph shows a hyperlucent zone in the right lower lobe with associated volume loss and a reduced number of lung vessels (arrows). (b) Prone expiratory CT scan shows decreased lung attenuation in the right lower lobe. The size and number of vessels are reduced. These findings are consistent with the presence of bronchiolar inflammatory disease with air trapping.
|
|
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15b. Gastric aspiration and obliterative bronchiolitis in a 68-year-old woman with achalasia. (a) Posteroanterior chest radiograph shows a hyperlucent zone in the right lower lobe with associated volume loss and a reduced number of lung vessels (arrows). (b) Prone expiratory CT scan shows decreased lung attenuation in the right lower lobe. The size and number of vessels are reduced. These findings are consistent with the presence of bronchiolar inflammatory disease with air trapping.
|
|
Lung Fibrosis
Gastroesophageal reflux and aspiration have been considered predisposing factors in the development of lung fibrosis (37). This fact is supported by the increased prevalence of hiatal hernia and gastroesophageal reflux in patients with idiopathic pulmonary fibrosis in comparison with control patients (37). However, this association remains controversial because a causal relationship between aspiration and pulmonary disease is difficult to prove (37). Thin-section CT findings related to lung fibrosis include lower lobe peripheral reticulopacities, honeycombing, and traction bronchiectasis (Fig 16).
View larger version (152K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16. Lung fibrosis related to a hiatal hernia with repetitive lung aspirations in a 63-year-old man. High-resolution CT scan shows a prominent reticular pattern with traction bronchiectasis and a hiatal hernia.
|
|
|
Conclusions
|
|---|
Esophageal perforation, esophagorespiratory fistulas, and motility disorders frequently result in abnormalities of the mediastinum, tracheobronchial tree, pleura, and lung. The most common complications include mediastinitis secondary to esophageal perforation or postoperative anastomotic leak, empyema due to fistula formation, and aspiration pneumonia. Because of the potentially high morbidity and mortality associated with these complications, early diagnosis is important. The radiologic manifestations are, however, often nonspecific. An awareness of the radiologic manifestations of these complications is thus required to facilitate early diagnosis.
|
References
|
|---|
- Blandergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg 1986; 42:235-239.[Abstract]
- Kerschner JE, Beste DJ, Conley SF, Kenna MA, Lee D. Mediastinitis associated with foreign body erosion of the esophagus in children. Int J Pediatr Otorhinolaryngol 2001; 59:89-97.[CrossRef][Medline]
- Eliashar R, Dano I, Dangcor E, Braverman I, Sichel JY. Computed tomography diagnosis of esophageal bone impaction: a prospective study. Ann Otol Rhinol Laryngol 1999; 108:708-710.[Medline]
- Douglas M, Sistrom CL. Chicken bone lodged in the upper esophagus: CT findings. Gastrointest Radiol 1991; 16:11-20.[CrossRef][Medline]
- Van Hise ML, Primack SL, Israel RS, Muller NL. CT in blunt chest trauma: indications and limitations. RadioGraphics 1998; 18:1071-1084.[Abstract]
- Macpherson RI, Hill JG, Othersen HB, et al. Esophageal foreign bodies in children: diagnosis, treatment and complications. AJR Am J Roentgenol 1996; 166:919-924.[Abstract/Free Full Text]
- Berry BE, Ochsner JR. Perforation of the esophagus: a 30 year review. J Thorac Cardiovasc Surg 1973; 65:1-7.[Medline]
- Love L, Berkow AE. Trauma to the esophagus. Gastrointest Radiol 1978; 2:305-321.[CrossRef][Medline]
- Levine MS. Trauma. Radiology of the esophagus. Philadelphia, Pa: Saunders, 1989; 209-227.
- Myers MA, Ghahremani GG. Complications of fiberoptic endoscopy. I. Esophagoscopy and gastroscopy. Radiology 1975; 115:293-300.
- Jenkins IR, Raymond R. Boerhaave’s syndrome complicated by a large bronchopleural fistula. Chest 1994; 105:964-965.[Abstract/Free Full Text]
- Duehring GL. Boerhaave’s syndrome. Radiol Technol 2000; 72:51-55.
- Hutzelmann A, Wesner F, Freund M, Heller M. Quiz case of the month: Boerhaave’s syndrome. Eur Radiol 1997; 7:293-294.[CrossRef][Medline]
- Noh HM, Fishman EK, Forastiere AA, Bliss DF, Calhoun PF. CT of the esophagus: spectrum of disease with emphasis on esophageal carcinoma. RadioGraphics 1995; 15:1113-1134.[Abstract]
- White CS, Templeton PA, Attar S. Esophageal perforation: CT findings. AJR Am J Roentgenol 1993; 160:767-770.[Abstract/Free Full Text]
- Heitzmann ER. General radiologic considerations. The mediastinum. 2nd ed. Heidelberg, Germany: Springer-Verlag, 1988; 7-43.
- Franquet T, Giménez A, Rosón N, Torrubia S, Sabaté JM, Pérez C. Aspiration diseases: findings, pitfalls, and differential diagnosis. RadioGraphics 2000; 20:673-685.[Abstract/Free Full Text]
- Cleveland RH. The pediatric airway. Contemp Diagn Radiol 1996; 19:1-6.
- Berrocal T, Torres I, Gutiérrez J, Prieto C, del Hoyo ML, Lamas M. Congenital anomalies of the upper gastrointestinal tract. RadioGraphics 1999; 19:855-872.[Abstract/Free Full Text]
- Carpenter BL, Merten DF. Radiographic manifestations of congenital anomalies affecting the airway. Radiol Clin North Am 1991; 29:219-240.[Medline]
- Han YM, Song HY, Lee JM, et al. Esophagorespiratory fistulae due to esophageal carcinoma: palliation with a covered Gianturco stent. Radiology 1996; 199:65-70.[Abstract/Free Full Text]
- Lee S, Mergo PJ, Ros PR. The leaking esophagus: CT patterns of esophageal rupture, perforation, and fistulization. Crit Rev Diagn Imaging 1996; 37:461-490.[Medline]
- Martini N, Goodner JT, D’Angio GJ, Battie EJ, Jr. Tracheoesophageal fistula due to cancer. J Thorac Cardiovasc Surg 1970; 49:319-324.
- Auban MM, Levine MS, Cohen RB, Rubesin SE, Laufer Y, Rosato EF. Delayed leaks and fistula after esophagogastrectomy: radiologic evaluation. AJR Am J Roentgenol 1993; 160:1217-1220.[Abstract/Free Full Text]
- Lepke RA, Libshitz HI. Radiation-induced injury to the esophagus. Radiology 1983; 148:375-378.[Abstract/Free Full Text]
- Sonomura T, Kishi K, Ishii S, et al. Usefulness of CT virtual endoscopy in imaging a large esophagorespiratory fistula. Eur J Radiol 2000; 34:60-62.[CrossRef][Medline]
- Berkman YM, Young HA. CT diagnosis of acquired tracheoesophageal fistula in adults. J Comput Assist Tomogr 1985; 9:302-306.[Medline]
- Wechsler RJ. CT of Esophageal-pleural fistulae. AJR Am J Roentgenol 1986; 147:907-909.[Abstract/Free Full Text]
- Prazy JP, Montgomery PQ, Reading N. Acute pneumonitis caused by low density barium sulphate aspiration. J Laryngol Otol 1993; 107:347-348.[Medline]
- Gray C, Sivaloganathan S, Simpkins KC. Aspiration of high-density barium contrast medium causing acute pulmonary inflammation: report of two fatal cases in elderly women with disordered swallowing. Clin Radiol 1989; 40:397-400.[CrossRef][Medline]
- Matsuse T, Oka T, Kida K, Fukuchi Y. Importance of diffuse aspiration caused by chronic occult aspiration in the elderly. Chest 1996; 110:1289-1293.[Abstract/Free Full Text]
- DePaso WJ. Aspiration pneumonia. Clin Chest Med 1991; 12:269-284.[Medline]
- David P, Denis P, Nouvet G, et al. Fonction respiratoire et reflux gastro-oesophagien au cours de la bronchite chronique. Bull Eur Physiopathol Respir 1982; 18:81-86.[Medline]
- Ayres JG, Miles JF. Oesophageal reflux and asthma. Eur Respir J 1996; 9:1073-1078.[Abstract]
- Harding SM, Schan CA, Guzzo MR, Alexander RW, Bradley LA, Richter JE. Gastroesophageal reflux-induced bronchoconstriction: is microaspiration a factor? Chest 1995; 108:1220-1227.[Abstract/Free Full Text]
- Worthy SA, Park CS, Kim JS, Muller NL. Bronchiolitis obliterans after lung transplantation: high resolution CT findings in 15 patients. AJR Am J Roentgenol 1997; 169:673-677.[Abstract/Free Full Text]
- Tobin RW, Pope CE, 2nd, Pellegrini CA, Emond MJ, Sillery J, Raghu G. Increased prevalence of gastroesophageal reflux in patients with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 1998; 158:1804-1808.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
C. A. Young, C. O. Menias, S. Bhalla, and S. R. Prasad
CT Features of Esophageal Emergencies
RadioGraphics,
October 1, 2008;
28(6):
1541 - 1553.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Ampollini and A. Bobbio
Reply to Giri and Sarkar
Eur. J. Cardiothorac. Surg.,
January 1, 2007;
31(1):
140 - 140.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
