Gastrointestinal perforation x-ray: Difference between revisions

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Revision as of 19:32, 30 December 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D [2]

Overview

Chest imaging

Findings of chest x-ray in esophageal perforation include:

Pneumomediastinum
Ring-around-the-artery sign in cases of pneumomediastinum: gas around pulmonary artery and main branches
Widening of the mediastinum
Free air under the diaphragm on upright films
Pleural effusion
Abnormal cardiomediastinal contour

Abdominal imaging

Free gas under the diaphragm is a classic sign of pneumoperitoneum on erect chest.
Cupola sign is an arcuate lucency over the lower thoracic spine. [98]
Rigler sign is seen as gas outlines the inner and outer surfaces of the intestine.
Psoas sign is air in the retroperitoneal space outlining the psoas muscle.
Urachus sign is air in the preperitoneal space outlining the urachus or umbilical ligaments.

Neck imaging

Signs of perforation on plain neck imaging include:

Subcutaneous emphysema tracking into the neck
Anterior displacement of the trachea
Air in the prevertebral fascial planes on lateral view

Endoscopy is an important tool for evaluating patients with suspected esophageal perforation, particularly following instrumentation, or related to noniatrogenic trauma [103,104]. Endoscopy allows direct inspection of the perforation and, in some cases, a therapeutic option. Endoscopy may show local erythema or spasm and essentially excludes the presence of the mucosal lesion. The disadvantage is the potential for causing a perforation with instrumentation. Nevertheless, in most cases, CT is obtained first because of its sensitivity and wide availability [105].

Ultrasound

although not a primary modality for evaluating pneumoperitoneum, free gas can be detected on ultrasound when gas shadowing is present along the peritoneum

make sure that the gas is not within the colon before deciding on calling pneumoperitoneum

X-ray abdomen and chest shows bowel perforation,source: Case courtesy of Dr Rahul Kulkarni, Radiopaedia.org, rID: 21444

Intestinal obstruction x-ray, source: Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 35721

@@ Line 6: / Line 6: @@
 ==Overview==
-Pneumomediastinum
+=== Chest imaging ===
+* Findings of chest x-ray in esophageal perforation include:
-The "V" sign of Naclerio is free air in the mediastinum outlining the diaphragm and is seen in approximately 20 percent of cases [97].
+* [[Pneumomediastinum]]
+* Ring-around-the-artery sign in cases of [[pneumomediastinum]]: gas around [[pulmonary artery]] and main branches
+* Widening of the [[mediastinum]]
+* Free air under the [[diaphragm]] on upright films
+* [[Pleural effusion]]
+* Abnormal cardiomediastinal contour
-Ring-around-the-artery sign
+=== Abdominal imaging ===
--Widening of the mediastinum is sometimes seen with esophageal perforation.
+* Free gas under the diaphragm is a classic sign of pneumoperitoneum on erect chest.
-•Free air under the diaphragm on upright films
+* Cupola sign is an arcuate lucency over the lower thoracic spine. [98]
+* [[Rigler's sign|Rigler sign]] is seen as gas outlines the inner and outer surfaces of the intestine.
+* [[Psoas sign]] is air in the retroperitoneal space outlining the psoas muscle.
+* [[Urachus]] sign is air in the preperitoneal space outlining the urachus or umbilical ligaments.
-Pleural effusion may represent leaked esophageal contents
+=== Neck imaging ===
+Signs of perforation on plain neck imaging include:
-Pneumothorax is a rare finding in esophageal perforation and is thought to occur by the spread of gas along tissue planes
+* [[Subcutaneous emphysema]] tracking into [[Neck|the neck]]
-Subcutaneous emphysema may be seen in some cases.
+* Anterior displacement of the [[trachea]]
+* Air in the [[Prevertebral fascia|prevertebral fascial]] planes on lateral view
-Abdominal imaging
-Plain abdominal films
-The appearance of pneumoperitoneum on plain films depends on the location of the air and patient positioning. Air outside the gastrointestinal tract (pneumoperitoneum) can be located freely in the peritoneal cavity, in the retroperitoneal spaces, in the mesentery, or in ligaments of organs. Extraluminal air may not be apparent if the perforation is small, has self-sealed, or has been contained by adjacent organs. Nonsurgical sources can also cause air in the peritoneal cavity
-Free air under the diaphragm in upright abdominal films (image 3), air over the liver (right lateral decubitus) or spleen (left lateral decubitus), anteriorly on supine films (football sign).
-Cupola sign (inverted cup) is an arcuate lucency over the lower thoracic spine [98]
-Rigler sign (double-wall sign) is seen as gas outlines the inner and outer surfaces of the intestine
-Psoas sign is air in the retroperitoneal space outlining the psoas muscle.
-Urachus sign is air in the preperitoneal space outlining the urachus or umbilical ligaments.
-Neck imaging
-Plain films
-Signs of perforation on plain neck imaging include subcutaneous emphysema tracking into the neck (image 2), anterior displacement of the trachea, and air in the prevertebral fascial planes on lateral view (image 7).
-Additional studies may be indicated as a means to further investigate a suspected perforation in a specific organ. Other imaging studies include endoscopy (upper, lower), esophagography, upper gastrointestinal series, ultrasound, contrast enema, and dye studies [101].
-It is important to note that for suspected perforation, barium should not be used initially as an oral contrast agent because it can produce granulomas in the tissues if it leaks out, and it can obscure abdominal findings on other imaging studies [101].
-However, if extravasation has not been demonstrated on initial water-soluble contrast studies and suspicion for perforation remains high, barium can be administered orally or transrectally depending on the suspected site of perforation, provided additional CT or arteriography is not planned [102].
 Endoscopy is an important tool for evaluating patients with suspected esophageal perforation, particularly following instrumentation, or related to noniatrogenic trauma [103,104]. Endoscopy allows direct inspection of the perforation and, in some cases, a therapeutic option. Endoscopy may show local erythema or spasm and essentially excludes the presence of the mucosal lesion. The disadvantage is the potential for causing a perforation with instrumentation. Nevertheless, in most cases, CT is obtained first because of its sensitivity and wide availability [105].
-Dye studies may be useful for evaluating patients with a pleural effusion and a thoracostomy tube who are suspected to have an esophageal leak. Methylene blue introduced cautiously via a nasoesophageal tube will make or confirm the diagnosis by causing blue discoloration of the chest tube drainage.
-Esophagus
-Plain radiograph
-Possible cues on chest radiographs include:
-pneumomediastinum, abnormal cardiomediastinal contour, pneumothorax and pleural effusion are all features, although non-specific, for oesophageal perforation 5
-•	widening of the mediastinal shadow: non-specific on its own
-Fluoroscopy
-most sensitive within the first 24 hours 1
-patient examined semi-supine on fluoroscopy table
-a water-soluble agent should be used initially as barium can cause mediastinitis
-oesophageal perforation may be represented as mucosal irregularity or gross extraluminal contrast extravasation
-some authors suggest the use of small amounts of low or high concentrations of barium if no leak is evident on initial screening with water soluble contrast 8
-Intestinal perforation
-'''Plain radiograph'''
-free gas under the diaphragm is a classic sign of pneumoperitoneum on erect chest and abdomen radiographs and it is suspicious for bowel perforation
-other signs of pneumoperitoneum, including Rigler's sign
 Ultrasound
@@ Line 85: / Line 36: @@
 make sure that the gas is not within the colon before deciding on calling pneumoperitoneum
-Fluoroscopy
-suspected gastroduodenal perforation
-an upper GI study with water-soluble contrast medium is not usually the primary study for detection of a suspected gastric or duodenal perforation but can be useful for confirmation of an equivocal appearance on CT or for detection of the precise location of a small perforation
-suspected small bowel perforation
-small bowel follow through is inferior to CT of the abdomen and pelvis with oral contrast for detection and localization of small bowel perforation
-suspected colonic perforation
-single contrast barium enema is not usually appropriate in the setting of colonic perforation
-the reason for colonic perforation is usually apparent and these patient are usually operated upon emergently
 [[File:Bowel-perforation.jpg|center|300px|thumb|X-ray abdomen and chest shows bowel perforation,source: Case courtesy of Dr Rahul Kulkarni, Radiopaedia.org, rID: 21444]]