- Email: [email protected]
If you see the contusion, there is no pneumothorax
106 preoperative diagnosis or suspicion of CRC between June 2007-July 2009 were evaluated retrospectively. The search revealed 4 patients with McKittrick-Wheelock syndrome. All patients were male, and their ages were 59, 67, 73, and 64, respectively. Our first patient was referred by our gastroenterology unit with secretory severe diarrhea and a diagnosis of villous adenoma at his third admission. Before his third admission, previous examinations had failed to reveal a diagnosis for this diarrhea. After the preoperative assessment, a low anterior resection of the rectum was carried out. The second and third patients were referred by the rural state hospital with a diagnosis of a giant villous lesion of the rectum and chronic renal failure that required hemodialysis due to severe electrolyte and liquid imbalance. Both were treated by abdominoperineal resection due to a giant villous lesion neighboring the anal canal. Although the fourth patient had secretory diarrhea during the last 3 months, he refused to be operated, because he did not accepted a permanent stoma. We solely recommended this patient octreotide acetate (Sandostatin-LAR; Novartis, Basel, Switzerland) and indomethacin (Endol; Deva, Istanbul), to suppress the symptoms. McKittrick-Wheelock syndrome is known as a rare cause of persistent diarrhea. However, it is not rare as often thought [3]. Upon presentation to the emergency department (ED), findings make the clinician think about the diagnosis of infective causes in the first place. However, repeated admissions should provoke a more invasive evaluation, such as sigmoidoscopy or colonoscopy, if necessary. Unless complications arise due to severe hydroelectrolyte disorders, McKittrick-Wheelock syndrome is a reversible illness with adequate treatment, so it is very important to make the diagnosis in precocious phases [3]. Despite all the warnings, McKittrick-Wheelock syndrome can result in renal insufficiency that requires temporarily or permanently hemodialysis, usually because of a delay in the diagnosis [4]. In the ED, identification of the primary pathology is unlikely without adequate appreciation and vigilance. The surgeon is thus often confronted with a complicated situation, and abdominoperineal resection is sometimes inevitable for giant villous lesions neighboring the anal canal. Cemil Caliskan MD Ozer Makay MD Ozgur Firat MD Alper Uğuz MD Erhan Akgün MD Mustafa A. Korkut MD Division of Proctology, Department of General Surgery Ege University School of Medicine, 35100 Bornova, Izmir, Turkey E-mail address: [email protected] doi:10.1016/j.ajem.2009.09.001
Correspondence
References [1] McKittrick LS, Wheelock FC. Carcinoma of the colon. Dis Colon Rectum 1997;40(12):1494-6. [2] Disario JA, Burt RW, Kandrick ML, et al. Colorectal cancers of rare histologic types compared with adenocarcinomas. Dis Colon Rect 1994;37:1227-30. [3] Martins HS, Brandao RA, Carvalho AL, et al. McKittrick-Wheelock syndrome: a cause of severe hydro-electrolyte disorders in ED. Am J Emerg Med 2007;25(9):1083. [4] Popescu A, Orban-Schiopu AM, Becheanu G, et al. McKittrickWheelock syndrome—a rare cause of acute renal failure. Rom J Gastroenterol 2005;14(1):63-6.
If you see the contusion, there is no pneumothorax To the Editor, We evaluated with interest the data from the study of Platz et al [1] recently published in the American Journal of Emergency Medicine. We agree with the high sensitivity attributed to chest ultrasonography in the diagnosis of pneumothorax (PNX), greater than that of chest radiography. We however disagree with the idea of a potential loss of accuracy toward diagnosis of PNX in case of pulmonary contusion. Furthermore, we consider incomplete an approach to an ultrasonographic diagnosis of PNX solely based on the presence or absence of lung sliding and that does not consider the presence of lung points [2] (specific of PNX) or of comet tail artifacts (B-lines) [3]. This latter sign, in particular, has the potential of being able to exclude PNX with 100% sensitivity, as B-lines actually originate from the visceral pleura. A study of ours, addressing echographic diagnosis of lung contusion, demonstrated that the presence of focal
Fig. 1 Lung point (large arrow). On the right side of the image, the parietal and visceral pleura are in contact, small comet tail artifacts appear (small arrows); on the left, the presence of air due to PNX covers all possible artifacts.
Correspondence
107 Sara Sher MD Anesthesia and Critical Care Department Fondazione Policlinico Mangiagalli e Regina Elena-IRCCS Milano, Italy Roberto Copetti MD Emergency Department S. Antonio Abate General Hospital Tolmezzo, Udine, Italy doi:10.1016/j.ajem.2009.09.003
References
Fig. 2 A small retroparietal anterior air collection (between the 2 arrows), a “double lung point,” covers all possible pleural artifacts, including power Doppler movement.
B-lines is a pattern characteristic of early contusion, present in 94% of cases [4]. Rocco et al [5] refer to a sensitivity of echography of 84% toward diagnosis of lung contusion. If we hypothesize that, in case of lung contusion, ultrasonographic lung scanning will rarely show a normal lung pattern and that presence of air in the pleural space acts as a specular reflector [6] that covers all possible underlying artifacts, evidence of comet tail artifacts, as in lung contusion, will exclude, by itself, the possibility of PNX. This appears evident in the study of a lung point shown in Fig. 1. Fig. 2 shows the presence of a double lung point own to a small anterior air bubble. This figure is also very explicative as it shows how all lung artifacts, and even the possibility of seeing Doppler movement, are hidden by the presence of an air bubble that displaces the visceral pleura from which lung artifacts have origin. It is thus clear that, whenever air is present, all artifacts created by underlying parenchymal disease will be masked. It is possible that lung sliding in a contused lung be reduced, for the smaller respiratory excursions and the reduced lung compliance [7], but this will not represent a problem in the diagnosis of PNX if all other accessory signs are evaluated—in particular, the echographic signs of lung contusion, which themselves exclude PNX. What the clinician will instead have to worry about is the possibility of the appearance of an echographic interstitial syndrome after PNX drainage, as this could be a sign of the presence of a lung contusion that was initially masked by the pleural air. Gino Soldati MD Emergency Department Valle del Serchio General Hospital Castelnuovo Garfagnana, Lucca, Italy E-mail address: [email protected]
[1] Platz E, Cydulka R, Werner S, et al. The effect of pulmonary contusions on lung sliding during bedside ultrasound. Am J Emerg Med 2009;27: 363-5. [2] Lichtenstein D, Mezière G, Biderman P, et al. The lung point: An ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26: 1434-40. [3] Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact. An ultrasound sign of alveolar interstitial syndrome. Am J Respir Crit Care Med 1997;156:1640-6. [4] Soldati G, Testa A, Silva FR, et al. Chest ultrasonography in lung contusion. Chest 2006;130:533-8. [5] Rocco M, Carbone I, Morelli A, et al. Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma. Acta Anaesthesiol Scand 2008;52:776-84. [6] Soldati G, Copetti R, Sher S. Sonographic interstitial syndrome: the sound of lung water. J Ultrasound Med 2009;28:163-74. [7] Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound 2008;29:16.
Response to: “If you see the contusion, there is no pneumothorax” To the Editor, We would like to thank the readers for their insightful comments. We agree that a combination of several sonographic findings and techniques, such as lung sliding, comet tails, lung point, M-mode, power Doppler, and others, may be needed to confidently rule out the presence of a pneumothorax. However, evaluating these combinations was not the objective of our study. Our study was designed to specifically evaluate whether lung sliding is affected by the presence of pulmonary contusions. This question is of interest because many clinicians consider lung sliding the mainstay of the sonographic evaluation of pneumothorax. The clinical problem was briefly addressed by Blaivas and colleagues [1] in 2005, which raised the concern that the presence of pulmonary contusions may affect lung sliding and limit the usefulness of ultrasound to exclude a pneumothorax under these circumstances. Further investigations are needed to clarify which sonographic technique(s) and artifacts allow for the highest
Correspondence
References [1] McKittrick LS, Wheelock FC. Carcinoma of the colon. Dis Colon Rectum 1997;40(12):1494-6. [2] Disario JA, Burt RW, Kandrick ML, et al. Colorectal cancers of rare histologic types compared with adenocarcinomas. Dis Colon Rect 1994;37:1227-30. [3] Martins HS, Brandao RA, Carvalho AL, et al. McKittrick-Wheelock syndrome: a cause of severe hydro-electrolyte disorders in ED. Am J Emerg Med 2007;25(9):1083. [4] Popescu A, Orban-Schiopu AM, Becheanu G, et al. McKittrickWheelock syndrome—a rare cause of acute renal failure. Rom J Gastroenterol 2005;14(1):63-6.
If you see the contusion, there is no pneumothorax To the Editor, We evaluated with interest the data from the study of Platz et al [1] recently published in the American Journal of Emergency Medicine. We agree with the high sensitivity attributed to chest ultrasonography in the diagnosis of pneumothorax (PNX), greater than that of chest radiography. We however disagree with the idea of a potential loss of accuracy toward diagnosis of PNX in case of pulmonary contusion. Furthermore, we consider incomplete an approach to an ultrasonographic diagnosis of PNX solely based on the presence or absence of lung sliding and that does not consider the presence of lung points [2] (specific of PNX) or of comet tail artifacts (B-lines) [3]. This latter sign, in particular, has the potential of being able to exclude PNX with 100% sensitivity, as B-lines actually originate from the visceral pleura. A study of ours, addressing echographic diagnosis of lung contusion, demonstrated that the presence of focal
Fig. 1 Lung point (large arrow). On the right side of the image, the parietal and visceral pleura are in contact, small comet tail artifacts appear (small arrows); on the left, the presence of air due to PNX covers all possible artifacts.
Correspondence
107 Sara Sher MD Anesthesia and Critical Care Department Fondazione Policlinico Mangiagalli e Regina Elena-IRCCS Milano, Italy Roberto Copetti MD Emergency Department S. Antonio Abate General Hospital Tolmezzo, Udine, Italy doi:10.1016/j.ajem.2009.09.003
References
Fig. 2 A small retroparietal anterior air collection (between the 2 arrows), a “double lung point,” covers all possible pleural artifacts, including power Doppler movement.
B-lines is a pattern characteristic of early contusion, present in 94% of cases [4]. Rocco et al [5] refer to a sensitivity of echography of 84% toward diagnosis of lung contusion. If we hypothesize that, in case of lung contusion, ultrasonographic lung scanning will rarely show a normal lung pattern and that presence of air in the pleural space acts as a specular reflector [6] that covers all possible underlying artifacts, evidence of comet tail artifacts, as in lung contusion, will exclude, by itself, the possibility of PNX. This appears evident in the study of a lung point shown in Fig. 1. Fig. 2 shows the presence of a double lung point own to a small anterior air bubble. This figure is also very explicative as it shows how all lung artifacts, and even the possibility of seeing Doppler movement, are hidden by the presence of an air bubble that displaces the visceral pleura from which lung artifacts have origin. It is thus clear that, whenever air is present, all artifacts created by underlying parenchymal disease will be masked. It is possible that lung sliding in a contused lung be reduced, for the smaller respiratory excursions and the reduced lung compliance [7], but this will not represent a problem in the diagnosis of PNX if all other accessory signs are evaluated—in particular, the echographic signs of lung contusion, which themselves exclude PNX. What the clinician will instead have to worry about is the possibility of the appearance of an echographic interstitial syndrome after PNX drainage, as this could be a sign of the presence of a lung contusion that was initially masked by the pleural air. Gino Soldati MD Emergency Department Valle del Serchio General Hospital Castelnuovo Garfagnana, Lucca, Italy E-mail address: [email protected]
[1] Platz E, Cydulka R, Werner S, et al. The effect of pulmonary contusions on lung sliding during bedside ultrasound. Am J Emerg Med 2009;27: 363-5. [2] Lichtenstein D, Mezière G, Biderman P, et al. The lung point: An ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26: 1434-40. [3] Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact. An ultrasound sign of alveolar interstitial syndrome. Am J Respir Crit Care Med 1997;156:1640-6. [4] Soldati G, Testa A, Silva FR, et al. Chest ultrasonography in lung contusion. Chest 2006;130:533-8. [5] Rocco M, Carbone I, Morelli A, et al. Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma. Acta Anaesthesiol Scand 2008;52:776-84. [6] Soldati G, Copetti R, Sher S. Sonographic interstitial syndrome: the sound of lung water. J Ultrasound Med 2009;28:163-74. [7] Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound 2008;29:16.
Response to: “If you see the contusion, there is no pneumothorax” To the Editor, We would like to thank the readers for their insightful comments. We agree that a combination of several sonographic findings and techniques, such as lung sliding, comet tails, lung point, M-mode, power Doppler, and others, may be needed to confidently rule out the presence of a pneumothorax. However, evaluating these combinations was not the objective of our study. Our study was designed to specifically evaluate whether lung sliding is affected by the presence of pulmonary contusions. This question is of interest because many clinicians consider lung sliding the mainstay of the sonographic evaluation of pneumothorax. The clinical problem was briefly addressed by Blaivas and colleagues [1] in 2005, which raised the concern that the presence of pulmonary contusions may affect lung sliding and limit the usefulness of ultrasound to exclude a pneumothorax under these circumstances. Further investigations are needed to clarify which sonographic technique(s) and artifacts allow for the highest