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Intramural esophageal dissection: CT imaging features
European Journal of Radiology Extra 56 (2005) 17–19
Intramural esophageal dissection: CT imaging features Mayil S. Krishnam a,∗ , Mohammed F. Ramadan b , John Curtis a a
Department of Radiology, University Hospital Aintree Lower Lane, Liverpool L9 7AL, UK Department of Surgery, University Hospital Aintree Lower Lane, Liverpool L9 7AL, UK
b
Received 25 May 2005; received in revised form 24 July 2005; accepted 25 July 2005
Abstract Intramural esophageal dissection (IED) is a rare but important condition to differentiate from a through perforation. We describe an interesting case in which multi-slice spiral computed tomography of the thorax was obtained immediately after the contrast swallow, to demonstrate features of intramural esophageal dissection. To the best of our knowledge, these CT appearances of intramural esophageal dissection have not yet been reported in the literature. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Esophagus; CT; Esophagus injury
1. Introduction Intramural esophageal dissection (IED) is due to a breach in the submucosal layer extending between the esophageal mucosa and muscular layer. It is important for the radiologist to differentiate the imaging features of IED from those of esophageal leak since the management of former is mainly conservative in contrast to the latter which often requires surgery [1]. IED is usually diagnosed by contrast swallow study but we describe an interesting case in which multi-slice spiral computed tomography (four-slice MDCT Toshiba Action Japan) of the thorax was obtained immediately after the contrast swallow, to demonstrate features of intramural esophageal dissection. To the best of our knowledge, these CT appearances of IED have not been reported yet in the literature. 2. Case A 90-year-old woman with a known history of recurrent benign esophageal stricture was admitted for an elective endoscopic stricture dilatation. Following endoscopic inter∗ Corresponding author. Present address: Department of Cardiovascular and Thoracic Radiology, David Geffen School of Medicine, University of California at Los Angeles, CA 90024, USA. Tel.: +1 310 4478850. E-mail address: [email protected] (M.S. Krishnam).
1571-4675/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2005.07.015
vention she had noticed lower neck pain while swallowing her oral secretion. A contrast swallow with a non-ionic watersoluble contrast medium, instead of endoscopy, was promptly performed to investigate the possibility of an esophageal perforation. It has demonstrated an extra luminal pool of contrast in a well-defined blind-ending tubular false channel. The false tract was lying parallel to the native esophagus and was extending from the cervical esophagus down to distal third of the esophagus (Fig. 1). A MSCT of the thorax was obtained immediately after the contrast swallow to evaluate the esophagus for a through perforation. CT showed no evidence of contrast leak or free air in the mediastinum, however, there was a high-density pool of contrast within the esophageal wall extending from the cervical to distal esophagus. In addition, MSCT also demonstrated a proximal communication point (Fig. 2a), a low-density mucosal flap (Fig. 2b) between the false and true lumen and intramural air. The CT features were pointing towards the diagnosis of intramural esophageal dissection. Following conservative management the patient made a complete recovery. A follow up contrast swallow study was performed weekly. Three weeks after the injury, the contrast swallow study was completely normal. 3. Discussion Intramural esophageal dissection following endoscopic intervention is caused by a mucosal tear, which extends
18
M.S. Krishnam et al. / European Journal of Radiology Extra 56 (2005) 17–19
Fig. 1. Contrast swallow demonstrates a large well defined false lumen (arrow) and a smaller true lumen of esophagus. Both lumens are separated by a thin radiolucent mucosal stripe (arrow).
into submucosa. The mucosal tear initially forms intramural esophageal haematoma (IEH), which may then progresses in the submucosal layer between the mucosa and muscular esophageal wall causing an intramural dissection [1]. The causes of IED are similar to IEH which include retching or vomiting, foreign body ingestion and mucosal perforation, forceful swallowing, anticoagulant therapy or spontaneous [1]. IED is common in elderly women and presents with chest pain, odynophagia, dysphagia and rarely haematemesis. Endoscopic features of an IED may include the presence of a mucosal tear, false lumen or mucosal bridge between the true and false lumen [2]. An esophageal contrast study may typically demonstrate contrast in the false and true lumen of the esophagus, which represents the so-called doublebarrelled esophagus [3]. The false lumen appears as a welldefined tubular, blind-ending structure, which is larger than the true lumen and lies parallel to the esophagus. Both lumens are separated by a thin radiolucent esophageal mucosa, which represents the mucosal stripe sign [3]. CT thorax with nonionic oral contrast administered just before the examination may demonstrate contrast within the esophageal wall (false lumen), a thin hypo dense mucosal flap separating the true and false lumen and an entry point of dissection. The high-density esophageal wall [2], intramural air bubbles and wall thickening are other reported features of esophageal dissection [4,5]. It is interesting to note that the MSCT features of IED are similar to those of spontaneous aortic dissection.
Fig. 2. (a) CT thorax with an oral contrast medium demonstrates a communication (entry) point of dissection between the true and false lumen of the esophagus (arrow). (b) CT thorax shows a thin low-density mucosal dissection flap separating the false and true lumen (arrow). In addition, intramural air bubble in the esophagus has also been demonstrated.
Intramural haematoma precedes the development of IED but it can occur as an isolated condition. Endoscopy may readily show purplish blue mucosal bulge into the esophageal lumen [2]. A contrast swallow study may show focal bulge with smooth outline towards the esophageal lumen. In an esophageal leak, the extra luminal contrast track is irregular and not necessarily parallel to the esophagus. Oral contrast may pool in the mediastinal or pleural spaces, which are readily seen on CT and it is usually accompanied by pneumomediastinum. When compared to plain radiography or fluoroscopy, MSCT of chest can more easily detects small amount of mediastinal free air due to small esophageal through perforation. Although it was a difficult procedure in our patient due to recurrent stricture and fibrosis, there was no evidence of mucosal tear while performing the esophageal dilatation. The contrast swallow has shown the typical double-barrelled
M.S. Krishnam et al. / European Journal of Radiology Extra 56 (2005) 17–19
esophagus and mucosal stripe sign. MSCT of thorax performed immediately after the contrast swallow has showed intramural contrast in the false lumen, a low-density mucosal dissection flap with an entry point of dissection and intramural air. Most patients as in our case will respond well with conservative management requiring oral restriction of fluids and solids, nutritional support, antibiotics and intravenous fluids [1]. These patients require weekly contrast swallow studies to assess the interval change. In conclusion, presence of double-barrel esophagus and a mucosal stripe sign on the contrast swallow should prompt the diagnosis of IED. In suspected patients, MSCT thorax, being performed immediately after oral contrast administration, may establish the diagnosis of IED with greater confidence by demonstrating intramural esophageal contrast and intramural
19
air without mediastinal air or fluid collection and therefore it can more reliably differentiate IED from esophageal through perforation. References [1] Hanson JM, Neilson D, Pettit SH. Intramural oesophageal dissection. Thorax 1991;46:524–7. [2] Hsu CC, Changchien CS. Endoscopic and radiological features of intramural esophageal dissection. Endoscopy 2001;33(4):379–81. [3] Lawman RK, Goldman R, Stern H. The roentgen aspects of intramural dissection of the esophagus. Radiology 1969;93:1329–31. [4] Constantine S. Oesophageal dissection: contrast studies and CT in diagnosis and monitoring. Aust Radiol 2003;47:198–201. [5] Herbetko J, Delany D, Ogilvie C, Blaquiere RM. Spontaneous intramural haematoma of the oesophagus: appearance on computed tomography. Clin Radiol 1991;44:327–8.
Intramural esophageal dissection: CT imaging features Mayil S. Krishnam a,∗ , Mohammed F. Ramadan b , John Curtis a a
Department of Radiology, University Hospital Aintree Lower Lane, Liverpool L9 7AL, UK Department of Surgery, University Hospital Aintree Lower Lane, Liverpool L9 7AL, UK
b
Received 25 May 2005; received in revised form 24 July 2005; accepted 25 July 2005
Abstract Intramural esophageal dissection (IED) is a rare but important condition to differentiate from a through perforation. We describe an interesting case in which multi-slice spiral computed tomography of the thorax was obtained immediately after the contrast swallow, to demonstrate features of intramural esophageal dissection. To the best of our knowledge, these CT appearances of intramural esophageal dissection have not yet been reported in the literature. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Esophagus; CT; Esophagus injury
1. Introduction Intramural esophageal dissection (IED) is due to a breach in the submucosal layer extending between the esophageal mucosa and muscular layer. It is important for the radiologist to differentiate the imaging features of IED from those of esophageal leak since the management of former is mainly conservative in contrast to the latter which often requires surgery [1]. IED is usually diagnosed by contrast swallow study but we describe an interesting case in which multi-slice spiral computed tomography (four-slice MDCT Toshiba Action Japan) of the thorax was obtained immediately after the contrast swallow, to demonstrate features of intramural esophageal dissection. To the best of our knowledge, these CT appearances of IED have not been reported yet in the literature. 2. Case A 90-year-old woman with a known history of recurrent benign esophageal stricture was admitted for an elective endoscopic stricture dilatation. Following endoscopic inter∗ Corresponding author. Present address: Department of Cardiovascular and Thoracic Radiology, David Geffen School of Medicine, University of California at Los Angeles, CA 90024, USA. Tel.: +1 310 4478850. E-mail address: [email protected] (M.S. Krishnam).
1571-4675/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2005.07.015
vention she had noticed lower neck pain while swallowing her oral secretion. A contrast swallow with a non-ionic watersoluble contrast medium, instead of endoscopy, was promptly performed to investigate the possibility of an esophageal perforation. It has demonstrated an extra luminal pool of contrast in a well-defined blind-ending tubular false channel. The false tract was lying parallel to the native esophagus and was extending from the cervical esophagus down to distal third of the esophagus (Fig. 1). A MSCT of the thorax was obtained immediately after the contrast swallow to evaluate the esophagus for a through perforation. CT showed no evidence of contrast leak or free air in the mediastinum, however, there was a high-density pool of contrast within the esophageal wall extending from the cervical to distal esophagus. In addition, MSCT also demonstrated a proximal communication point (Fig. 2a), a low-density mucosal flap (Fig. 2b) between the false and true lumen and intramural air. The CT features were pointing towards the diagnosis of intramural esophageal dissection. Following conservative management the patient made a complete recovery. A follow up contrast swallow study was performed weekly. Three weeks after the injury, the contrast swallow study was completely normal. 3. Discussion Intramural esophageal dissection following endoscopic intervention is caused by a mucosal tear, which extends
18
M.S. Krishnam et al. / European Journal of Radiology Extra 56 (2005) 17–19
Fig. 1. Contrast swallow demonstrates a large well defined false lumen (arrow) and a smaller true lumen of esophagus. Both lumens are separated by a thin radiolucent mucosal stripe (arrow).
into submucosa. The mucosal tear initially forms intramural esophageal haematoma (IEH), which may then progresses in the submucosal layer between the mucosa and muscular esophageal wall causing an intramural dissection [1]. The causes of IED are similar to IEH which include retching or vomiting, foreign body ingestion and mucosal perforation, forceful swallowing, anticoagulant therapy or spontaneous [1]. IED is common in elderly women and presents with chest pain, odynophagia, dysphagia and rarely haematemesis. Endoscopic features of an IED may include the presence of a mucosal tear, false lumen or mucosal bridge between the true and false lumen [2]. An esophageal contrast study may typically demonstrate contrast in the false and true lumen of the esophagus, which represents the so-called doublebarrelled esophagus [3]. The false lumen appears as a welldefined tubular, blind-ending structure, which is larger than the true lumen and lies parallel to the esophagus. Both lumens are separated by a thin radiolucent esophageal mucosa, which represents the mucosal stripe sign [3]. CT thorax with nonionic oral contrast administered just before the examination may demonstrate contrast within the esophageal wall (false lumen), a thin hypo dense mucosal flap separating the true and false lumen and an entry point of dissection. The high-density esophageal wall [2], intramural air bubbles and wall thickening are other reported features of esophageal dissection [4,5]. It is interesting to note that the MSCT features of IED are similar to those of spontaneous aortic dissection.
Fig. 2. (a) CT thorax with an oral contrast medium demonstrates a communication (entry) point of dissection between the true and false lumen of the esophagus (arrow). (b) CT thorax shows a thin low-density mucosal dissection flap separating the false and true lumen (arrow). In addition, intramural air bubble in the esophagus has also been demonstrated.
Intramural haematoma precedes the development of IED but it can occur as an isolated condition. Endoscopy may readily show purplish blue mucosal bulge into the esophageal lumen [2]. A contrast swallow study may show focal bulge with smooth outline towards the esophageal lumen. In an esophageal leak, the extra luminal contrast track is irregular and not necessarily parallel to the esophagus. Oral contrast may pool in the mediastinal or pleural spaces, which are readily seen on CT and it is usually accompanied by pneumomediastinum. When compared to plain radiography or fluoroscopy, MSCT of chest can more easily detects small amount of mediastinal free air due to small esophageal through perforation. Although it was a difficult procedure in our patient due to recurrent stricture and fibrosis, there was no evidence of mucosal tear while performing the esophageal dilatation. The contrast swallow has shown the typical double-barrelled
M.S. Krishnam et al. / European Journal of Radiology Extra 56 (2005) 17–19
esophagus and mucosal stripe sign. MSCT of thorax performed immediately after the contrast swallow has showed intramural contrast in the false lumen, a low-density mucosal dissection flap with an entry point of dissection and intramural air. Most patients as in our case will respond well with conservative management requiring oral restriction of fluids and solids, nutritional support, antibiotics and intravenous fluids [1]. These patients require weekly contrast swallow studies to assess the interval change. In conclusion, presence of double-barrel esophagus and a mucosal stripe sign on the contrast swallow should prompt the diagnosis of IED. In suspected patients, MSCT thorax, being performed immediately after oral contrast administration, may establish the diagnosis of IED with greater confidence by demonstrating intramural esophageal contrast and intramural
19
air without mediastinal air or fluid collection and therefore it can more reliably differentiate IED from esophageal through perforation. References [1] Hanson JM, Neilson D, Pettit SH. Intramural oesophageal dissection. Thorax 1991;46:524–7. [2] Hsu CC, Changchien CS. Endoscopic and radiological features of intramural esophageal dissection. Endoscopy 2001;33(4):379–81. [3] Lawman RK, Goldman R, Stern H. The roentgen aspects of intramural dissection of the esophagus. Radiology 1969;93:1329–31. [4] Constantine S. Oesophageal dissection: contrast studies and CT in diagnosis and monitoring. Aust Radiol 2003;47:198–201. [5] Herbetko J, Delany D, Ogilvie C, Blaquiere RM. Spontaneous intramural haematoma of the oesophagus: appearance on computed tomography. Clin Radiol 1991;44:327–8.