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Acute intrathoracic intestinal strangulation diagnosed by transthoracic echocardiography
CLINICAL SPOTLIGHT
Clinical Spotlight
Acute intrathoracic intestinal strangulation diagnosed by transthoracic echocardiography Om Narayan, MBBS (Hons.), BMedSci ∗ , Catherine Liew, MBBS, BMedSci, Elizabeth Ryan, FRACP, John Amerena, MD, FRACP, Alan Appelbe, FRACP and Alexander Black, MD, FRACP Department of Cardiology, Geelong Hospital, Ryrie Street, Geelong, VIC 3220, Australia
Transthoracic echocardiography plays a central role in diagnosing a variety of cardiac and pericardial disorders. However its use in identifying extra-cardiac thoracic pathology is less well recognised. We describe an unusual case of intrathoracic intestinal strangulation detected by transthoracic echocardiography. The recognition of bowel loops within the left hemithorax enabled rapid confirmatory computed tomographic imaging and subsequent life-saving surgery. This case demonstrates the utility of bedside echocardiography in the assessment of intrathoracic pathology and emphasises the need for cardiologists to be familiar with the echocardiographic appearance of these disorders. (Heart, Lung and Circulation 2012;21:831–835) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved. Keywords. Echocardiography; Spontaneous diaphragmatic rupture; Temporary transvenous pacing; 3rd degree AV block
Introduction
T
ransthoracic echocardiography (TTE) is widely used to evaluate patients with suspected cardiac dysfunction. Not infrequently ancillary pathology may be detected, including pleural effusions, hepatic lesions or extracardiac masses. We describe a patient who developed symptoms of small bowel obstruction and a new pleural density on chest X-ray following temporary pacing wire insertion. Bedside TTE led to the detection of bowel and a large pleural effusion within the left thoracic cavity leading to the subsequent diagnosis of trans-diaphragmatic bowel herniation and strangulation.
Case Description A 75 year-old man presented following an unwitnessed collapse, preceded by a two-week prodrome of episodic pre-syncope and increasing lethargy. He had a history of oesophageal carcinoma for which he had undergone surgical resection with adjuvant chemotherapy seven years previously. No evidence of local recurrence or distal metastasis was observed on routine expectant management. A small, asymptomatic hiatal hernia adjacent the surgically modified gastrodiaphragmatic junction was Received 18 October 2011; received in revised form 31 January 2012; accepted 25 April 2012; available online 1 June 2012 ∗ Corresponding author at: Geelong Cardiology Practice, The Geelong Hospital, Ryrie St. Geelong 3220, Australia. Tel.: +61 403363844; fax: +61 03 8677 9091. E-mail address: om [email protected] (O. Narayan).
noted incidentally on postoperative CT scans. Visceral herniation via this defect was not noted. On examination he was markedly bradycardic due to 3rd degree AV block (Fig. 1a and b). Atropine was administered with transient effect. An adrenaline infusion was commenced with titration to blood pressure goals. The patient developed nausea and vomiting. This was initially attributed to significant hypotension and emergency drug therapy. Treatment with metoclopramide 10 mg as an intravenous bolus was given. Due to persistent bradycardia, a temporary pacing wire was subsequently inserted via a 7.5 French sheath in the right internal jugular vein under fluoroscopic guidance and positioned at the right ventricular apex. Ventricular capture was confirmed and the patient was paced at a rate of 75 beats per minute. A routine post procedure portable chest X-ray was performed (see Fig. 2). Despite restoration of haemodynamic stability, nausea and vomiting persisted and therapy with metoclopramide, ondansetron and prochlorperazine was instituted with only moderate symptom relief. Diffuse abdominal pain gradually developed. Repeat clinical examination revealed the presence of a new left sided pleural effusion and the absence of abdominal tenderness. An urgent chest X-ray was performed, demonstrating a new left sided pleural density together with displacement of the cardiac silhouette (see Fig. 3). These findings had been notably absent on the chest X-ray performed following temporary pacing wire insertion. Laboratory results revealed the presence of a lactic acidosis with a lactate of 7.6 mmol/L. An urgent transthoracic
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.04.019
832
Narayan et al. Acute intrathoracic intestinal strangulation
Heart, Lung and Circulation 2012;21:831–835
CLINICAL SPOTLIGHT
Figure 1. (a) Initial 12 lead ECG demonstrating complete heart block with a slow escape rhythm. (b) Rhythm strip (leads V2 and II) demonstrating intermittent severe bradycardia (rate approx 20 bpm).
echocardiogram was subsequently performed to investigate for possible temporary pacing wire associated perforation. Transthoracic echocardiography in the left parasternal view demonstrated displacement of the heart posteromedially with loops of bowel clearly visible within the thoracic cavity (see Fig. 4a–c). An associated pleural effusion was also evident (see Fig. 4a). Due to gross displacement of the heart, standard views to rule out pericardial effusion and cardiac dysfunction could not be obtained. A computed tomographic (CT) scan of the chest and abdomen was performed which confirmed the presence of multiple herniated loops of bowel with associated mesentery within the left thoracic cavity (Fig. 5). Possible bowel infarction was suspected due to poor enhancement with intravenous contrast. The patient underwent emergent laparotomy where a large left diaphragmatic defect was discovered. The diaphragmatic defect was enlarged to facilitate retrieval of three metres of infarcted non-viable bowel. An en-bloc resection was performed and a primary anastomosis
fashioned with the remaining jejunum and ileum. A defunctioning loop ileostomy was created and the diaphragmatic defect was left open. On the third postoperative day, a dual chamber permanent pacemaker was inserted. The patient recovered uneventfully from both procedures and was discharged on the 12th postoperative day. At six-month follow-up, the patient reported a full clinical recovery with no residual abdominal or cardiac symptomatology.
Discussion Whilst diaphragmatic herniation is a recognised rare complication of oesophagectomy, the acute herniation and subsequent strangulation of a large segment of small bowel into the left hemi-thorax seven years following this surgery has not previously been reported [1–3]. As oesophageal resection with gastric “pull-up” invariably involves dissection of the diaphragmatic oesophageal hiatus and anterolateral incision of the diaphragm, formation of post-operative hernias is relatively common (4%). In
Narayan et al. Acute intrathoracic intestinal strangulation
833 CLINICAL SPOTLIGHT
Heart, Lung and Circulation 2012;21:831–835
Figure 2. Chest X-ray performed in the AP projection immediately following pacing wire insertion, demonstrating wire placement at the right ventricular apex and an enlarged cardiomediastinal contour.
a surgical series reported by Van Sandick et al., intrathoracic herniation of abdominal contents occurred in nine of 218 patients after oesophagectomy. Of these, six patients presented with symptoms attributable to herniation (bowel obstruction, dyspnoea, cough, constipation and abdominal pain) [4]. Given that the patient was known to have a small para-hiatal diaphragmatic hernia, we considered the possibility that the intestinal herniation and strangulation predated the patient’s initial presentation with complete heart block. However the initial chest Xray performed following pacing wire insertion failed to demonstrate a significant intrathoracic abnormality. The subsequent development of a large left pleural effusion on the chest X-ray performed the next day suggests that visceral herniation occurred in the hours following pacing wire insertion. Therefore we postulate that a pre-existing defect in the hiatal region extended due to vomiting, resulting in the subsequent herniation and incarceration of small bowel. Temporary pacing wire placement and the development of this complication were likely unrelated. Nausea and vomiting may have been initiated through severe hypotension and the administration of medications administered during resuscitation. Persistent vomiting was likely a consequence of established small bowel obstruction and infarction. Prior to the bedside transthoracic echocardiogram, acute haemothorax as a complication of pacing wire insertion was initially suspected and emergent thoracentesis
Figure 3. Emergency chest X-ray performed at time of clinical deterioration with intractable nausea and vomiting.
would have been performed, if not for the demonstration of loops of bowel within the pleural cavity. Acute tamponade relating to temporary pacing wire insertion is well described and we postulated perforation of the pericardium leading to fistulisation of the right ventricle to the left pleural space as the cause for the new pleural density [5–7]. Additionally, previous case reports have described diaphragmatic perforation secondary to temporary pacing wire migration [6]. CT imaging in this case clearly ruled out both the above possibilities. The diagnosis of trans-diaphragmatic bowel herniation is often suspected through the identification of gas filled bowel loops within the thoracic cavity on chest X-ray – a finding absent in our patient’s case. As has been demonstrated, bedside echocardiography offers the means to rapidly evaluate acute pleural effusions, where trans-diaphragmatic herniation is in consideration. Bedside echocardiography is portable, avoids radiation and contrast exposure to the patient and may be performed concurrently with active resuscitation. Bedside echocardiography however cannot confirm the presence of strangulation nor define the extent of herniation. Consequently echocardiography will remain an adjunct to imaging of intrathoracic pathology and any findings will require confirmation with other established imaging modalities, such as computed tomography.
834
Narayan et al. Acute intrathoracic intestinal strangulation
Heart, Lung and Circulation 2012;21:831–835
CLINICAL SPOTLIGHT
Figure 5. Computed tomographic imaging with intravenous contrast reconstructed in a coronal section. Multiple loops of small bowel with associated mesentery is clearly demonstrated within the left hemithorax. A pleural effusion is also present. The mediastinum is displaced due to mass effect.
The possibility of diaphragmatic rupture with herniation and strangulation of bowel is often overlooked in patients presenting with intestinal obstructive symptoms. Often, the original injury predisposing to rupture is obscure [3]. In those patients with a prior history of upper abdominal/oesophageal surgery, consideration of this entity is warranted and may avert a poor outcome. In patients presenting with a pleural density on chest radiography and symptoms of bowel obstruction, bedside ultrasonography may facilitate early diagnosis of this potentially fatal condition.
Acknowledgement No financial or technical assistance was received in the preparation of this manuscript.
References Figure 4. (a–c) Parasternal echocardiographic imaging of the left hemithorax demonstrating loops of bowel in oblique section with associated fluid density. (c) Parasternal echocardiographic imaging of the left hemithorax demonstrating multiple loops of bowel in short axis with a short axis view of the heart.
[1] Vallbohmer D, Holscher AH, Herbold T, Gutschow C, Schroder W. Diaphragmatic hernia after conventional or laparoscopic-assisted transthoracic esophagectomy. Ann Thorac Surg 2007;84(6):1847–52. [2] Ellison EH. Diaphragmatic hernia; a review of the literature and report of two unusual cases. Am J Surg 1949;77(2):152–61. [3] Vyas S, Sarkar S, Mitchell I, Stoker D. Delayed transhiatal herniation of the small bowel after Ivor Lewis esophagectomy. Minerva Chir 2009;64(4):427–9. [4] Van Sandick JW, Knegjens JL, van Lanschot JJ, Obertop H. Diaphragmatic herniation following oesophagectomy. Br J Surg 1999;86(1):109–12.
[5] Nashed G, French B, Gallagher D, Hopkins A, Juergens C, Leung D. Right ventricular perforation with cardiac tamponade associated with use of a temporary pacing wire and abciximab during complex coronary angioplasty. Catheter Cardiovasc Interv 1999;48(4):388–9. [6] Madershahian N, Wippermann J, Wahlers T. The bite of the lead: multiorgan perforation by an active-fixation
Narayan et al. Acute intrathoracic intestinal strangulation
835
permanent pacemaker lead. Interact Cardiovasc Thorac Surg 2010;11(1):93–4. [7] Trehan V, Mehta V, Mukhopadhay S, Yusuf J, Rastogi V, Yaduvanshi A. Nonsurgical management of cardiac tamponade caused by a temporary pacemaker lead. Pacing Clin Electrophysiol 2005;28(3):242–4.
CLINICAL SPOTLIGHT
Heart, Lung and Circulation 2012;21:831–835
Clinical Spotlight
Acute intrathoracic intestinal strangulation diagnosed by transthoracic echocardiography Om Narayan, MBBS (Hons.), BMedSci ∗ , Catherine Liew, MBBS, BMedSci, Elizabeth Ryan, FRACP, John Amerena, MD, FRACP, Alan Appelbe, FRACP and Alexander Black, MD, FRACP Department of Cardiology, Geelong Hospital, Ryrie Street, Geelong, VIC 3220, Australia
Transthoracic echocardiography plays a central role in diagnosing a variety of cardiac and pericardial disorders. However its use in identifying extra-cardiac thoracic pathology is less well recognised. We describe an unusual case of intrathoracic intestinal strangulation detected by transthoracic echocardiography. The recognition of bowel loops within the left hemithorax enabled rapid confirmatory computed tomographic imaging and subsequent life-saving surgery. This case demonstrates the utility of bedside echocardiography in the assessment of intrathoracic pathology and emphasises the need for cardiologists to be familiar with the echocardiographic appearance of these disorders. (Heart, Lung and Circulation 2012;21:831–835) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved. Keywords. Echocardiography; Spontaneous diaphragmatic rupture; Temporary transvenous pacing; 3rd degree AV block
Introduction
T
ransthoracic echocardiography (TTE) is widely used to evaluate patients with suspected cardiac dysfunction. Not infrequently ancillary pathology may be detected, including pleural effusions, hepatic lesions or extracardiac masses. We describe a patient who developed symptoms of small bowel obstruction and a new pleural density on chest X-ray following temporary pacing wire insertion. Bedside TTE led to the detection of bowel and a large pleural effusion within the left thoracic cavity leading to the subsequent diagnosis of trans-diaphragmatic bowel herniation and strangulation.
Case Description A 75 year-old man presented following an unwitnessed collapse, preceded by a two-week prodrome of episodic pre-syncope and increasing lethargy. He had a history of oesophageal carcinoma for which he had undergone surgical resection with adjuvant chemotherapy seven years previously. No evidence of local recurrence or distal metastasis was observed on routine expectant management. A small, asymptomatic hiatal hernia adjacent the surgically modified gastrodiaphragmatic junction was Received 18 October 2011; received in revised form 31 January 2012; accepted 25 April 2012; available online 1 June 2012 ∗ Corresponding author at: Geelong Cardiology Practice, The Geelong Hospital, Ryrie St. Geelong 3220, Australia. Tel.: +61 403363844; fax: +61 03 8677 9091. E-mail address: om [email protected] (O. Narayan).
noted incidentally on postoperative CT scans. Visceral herniation via this defect was not noted. On examination he was markedly bradycardic due to 3rd degree AV block (Fig. 1a and b). Atropine was administered with transient effect. An adrenaline infusion was commenced with titration to blood pressure goals. The patient developed nausea and vomiting. This was initially attributed to significant hypotension and emergency drug therapy. Treatment with metoclopramide 10 mg as an intravenous bolus was given. Due to persistent bradycardia, a temporary pacing wire was subsequently inserted via a 7.5 French sheath in the right internal jugular vein under fluoroscopic guidance and positioned at the right ventricular apex. Ventricular capture was confirmed and the patient was paced at a rate of 75 beats per minute. A routine post procedure portable chest X-ray was performed (see Fig. 2). Despite restoration of haemodynamic stability, nausea and vomiting persisted and therapy with metoclopramide, ondansetron and prochlorperazine was instituted with only moderate symptom relief. Diffuse abdominal pain gradually developed. Repeat clinical examination revealed the presence of a new left sided pleural effusion and the absence of abdominal tenderness. An urgent chest X-ray was performed, demonstrating a new left sided pleural density together with displacement of the cardiac silhouette (see Fig. 3). These findings had been notably absent on the chest X-ray performed following temporary pacing wire insertion. Laboratory results revealed the presence of a lactic acidosis with a lactate of 7.6 mmol/L. An urgent transthoracic
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.04.019
832
Narayan et al. Acute intrathoracic intestinal strangulation
Heart, Lung and Circulation 2012;21:831–835
CLINICAL SPOTLIGHT
Figure 1. (a) Initial 12 lead ECG demonstrating complete heart block with a slow escape rhythm. (b) Rhythm strip (leads V2 and II) demonstrating intermittent severe bradycardia (rate approx 20 bpm).
echocardiogram was subsequently performed to investigate for possible temporary pacing wire associated perforation. Transthoracic echocardiography in the left parasternal view demonstrated displacement of the heart posteromedially with loops of bowel clearly visible within the thoracic cavity (see Fig. 4a–c). An associated pleural effusion was also evident (see Fig. 4a). Due to gross displacement of the heart, standard views to rule out pericardial effusion and cardiac dysfunction could not be obtained. A computed tomographic (CT) scan of the chest and abdomen was performed which confirmed the presence of multiple herniated loops of bowel with associated mesentery within the left thoracic cavity (Fig. 5). Possible bowel infarction was suspected due to poor enhancement with intravenous contrast. The patient underwent emergent laparotomy where a large left diaphragmatic defect was discovered. The diaphragmatic defect was enlarged to facilitate retrieval of three metres of infarcted non-viable bowel. An en-bloc resection was performed and a primary anastomosis
fashioned with the remaining jejunum and ileum. A defunctioning loop ileostomy was created and the diaphragmatic defect was left open. On the third postoperative day, a dual chamber permanent pacemaker was inserted. The patient recovered uneventfully from both procedures and was discharged on the 12th postoperative day. At six-month follow-up, the patient reported a full clinical recovery with no residual abdominal or cardiac symptomatology.
Discussion Whilst diaphragmatic herniation is a recognised rare complication of oesophagectomy, the acute herniation and subsequent strangulation of a large segment of small bowel into the left hemi-thorax seven years following this surgery has not previously been reported [1–3]. As oesophageal resection with gastric “pull-up” invariably involves dissection of the diaphragmatic oesophageal hiatus and anterolateral incision of the diaphragm, formation of post-operative hernias is relatively common (4%). In
Narayan et al. Acute intrathoracic intestinal strangulation
833 CLINICAL SPOTLIGHT
Heart, Lung and Circulation 2012;21:831–835
Figure 2. Chest X-ray performed in the AP projection immediately following pacing wire insertion, demonstrating wire placement at the right ventricular apex and an enlarged cardiomediastinal contour.
a surgical series reported by Van Sandick et al., intrathoracic herniation of abdominal contents occurred in nine of 218 patients after oesophagectomy. Of these, six patients presented with symptoms attributable to herniation (bowel obstruction, dyspnoea, cough, constipation and abdominal pain) [4]. Given that the patient was known to have a small para-hiatal diaphragmatic hernia, we considered the possibility that the intestinal herniation and strangulation predated the patient’s initial presentation with complete heart block. However the initial chest Xray performed following pacing wire insertion failed to demonstrate a significant intrathoracic abnormality. The subsequent development of a large left pleural effusion on the chest X-ray performed the next day suggests that visceral herniation occurred in the hours following pacing wire insertion. Therefore we postulate that a pre-existing defect in the hiatal region extended due to vomiting, resulting in the subsequent herniation and incarceration of small bowel. Temporary pacing wire placement and the development of this complication were likely unrelated. Nausea and vomiting may have been initiated through severe hypotension and the administration of medications administered during resuscitation. Persistent vomiting was likely a consequence of established small bowel obstruction and infarction. Prior to the bedside transthoracic echocardiogram, acute haemothorax as a complication of pacing wire insertion was initially suspected and emergent thoracentesis
Figure 3. Emergency chest X-ray performed at time of clinical deterioration with intractable nausea and vomiting.
would have been performed, if not for the demonstration of loops of bowel within the pleural cavity. Acute tamponade relating to temporary pacing wire insertion is well described and we postulated perforation of the pericardium leading to fistulisation of the right ventricle to the left pleural space as the cause for the new pleural density [5–7]. Additionally, previous case reports have described diaphragmatic perforation secondary to temporary pacing wire migration [6]. CT imaging in this case clearly ruled out both the above possibilities. The diagnosis of trans-diaphragmatic bowel herniation is often suspected through the identification of gas filled bowel loops within the thoracic cavity on chest X-ray – a finding absent in our patient’s case. As has been demonstrated, bedside echocardiography offers the means to rapidly evaluate acute pleural effusions, where trans-diaphragmatic herniation is in consideration. Bedside echocardiography is portable, avoids radiation and contrast exposure to the patient and may be performed concurrently with active resuscitation. Bedside echocardiography however cannot confirm the presence of strangulation nor define the extent of herniation. Consequently echocardiography will remain an adjunct to imaging of intrathoracic pathology and any findings will require confirmation with other established imaging modalities, such as computed tomography.
834
Narayan et al. Acute intrathoracic intestinal strangulation
Heart, Lung and Circulation 2012;21:831–835
CLINICAL SPOTLIGHT
Figure 5. Computed tomographic imaging with intravenous contrast reconstructed in a coronal section. Multiple loops of small bowel with associated mesentery is clearly demonstrated within the left hemithorax. A pleural effusion is also present. The mediastinum is displaced due to mass effect.
The possibility of diaphragmatic rupture with herniation and strangulation of bowel is often overlooked in patients presenting with intestinal obstructive symptoms. Often, the original injury predisposing to rupture is obscure [3]. In those patients with a prior history of upper abdominal/oesophageal surgery, consideration of this entity is warranted and may avert a poor outcome. In patients presenting with a pleural density on chest radiography and symptoms of bowel obstruction, bedside ultrasonography may facilitate early diagnosis of this potentially fatal condition.
Acknowledgement No financial or technical assistance was received in the preparation of this manuscript.
References Figure 4. (a–c) Parasternal echocardiographic imaging of the left hemithorax demonstrating loops of bowel in oblique section with associated fluid density. (c) Parasternal echocardiographic imaging of the left hemithorax demonstrating multiple loops of bowel in short axis with a short axis view of the heart.
[1] Vallbohmer D, Holscher AH, Herbold T, Gutschow C, Schroder W. Diaphragmatic hernia after conventional or laparoscopic-assisted transthoracic esophagectomy. Ann Thorac Surg 2007;84(6):1847–52. [2] Ellison EH. Diaphragmatic hernia; a review of the literature and report of two unusual cases. Am J Surg 1949;77(2):152–61. [3] Vyas S, Sarkar S, Mitchell I, Stoker D. Delayed transhiatal herniation of the small bowel after Ivor Lewis esophagectomy. Minerva Chir 2009;64(4):427–9. [4] Van Sandick JW, Knegjens JL, van Lanschot JJ, Obertop H. Diaphragmatic herniation following oesophagectomy. Br J Surg 1999;86(1):109–12.
[5] Nashed G, French B, Gallagher D, Hopkins A, Juergens C, Leung D. Right ventricular perforation with cardiac tamponade associated with use of a temporary pacing wire and abciximab during complex coronary angioplasty. Catheter Cardiovasc Interv 1999;48(4):388–9. [6] Madershahian N, Wippermann J, Wahlers T. The bite of the lead: multiorgan perforation by an active-fixation
Narayan et al. Acute intrathoracic intestinal strangulation
835
permanent pacemaker lead. Interact Cardiovasc Thorac Surg 2010;11(1):93–4. [7] Trehan V, Mehta V, Mukhopadhay S, Yusuf J, Rastogi V, Yaduvanshi A. Nonsurgical management of cardiac tamponade caused by a temporary pacemaker lead. Pacing Clin Electrophysiol 2005;28(3):242–4.
CLINICAL SPOTLIGHT
Heart, Lung and Circulation 2012;21:831–835