0:01

So for this next case, this is actually an inpatient who was

0:04

being seen by the emergency team, because after hours, oftentimes the emergency

0:11

and the acute care populations are treated and seen by the same teams.

0:17

So this came across our board, and this was a patient who was 63 years

0:22

old, and he had had a stent placed across his GE junction for esophageal cancer.

0:29

And he now is presenting with spiking fevers and difficulty breathing.

0:34

So let's go through and see what we find. Going through in our standard approach,

0:38

let's take a look at the lines and tubes and identify those.

0:42

And there are a number of chest tubes.

0:44

One here that's seen on the right that is positioned apically.

0:49

There's also one that we see here in the basilar area.

0:54

There's another one here on the right base that we see.

0:57

So we've got probably three chest tubes.

1:00

We've got a central venous,

1:02

probably a PICC line here heading toward the central region.

1:06

And let's see if we can figure out where it ends.

1:09

It's hard to see it beyond the SVC.

1:13

There are overlying, you know, oxygen tubing,

1:15

there's overlying monitoring wires across the field.

1:21

And if you window down, you can see nicely here the stent across the GE junction.

1:30

So we've covered our lines and tube. Below the left lung zone,

1:36

other than there being low lung volumes, I don't see any focal consolidation.

1:40

I don't see that there's any evidence of pneumothorax.

1:45

We do have almost a layering air fluid

1:48

level, kind of pleural effusion that's happening here on the right side.

1:53

Let's just window down a little bit better,

1:56

where you can see kind of a nice air fluid level that's been created.

2:01

We're not seeing the costophrenic angle very well.

2:03

So this is something we definitely like

2:05

to better understand in a patient who's recently gone under a procedure.

2:10

He's got multiple lines and tubes who clearly have some underlying pathology

2:14

to understand what's really going on better here.

2:17

So, it could be a loculated pleural effusion,

2:20

it could be related to the esophagus itself.

2:23

Not really clear, but we'll kind of raise

2:25

some questions and really recommend that the patient get a CT.

2:30

Let's not forget about our lateral view.

2:32

And again, you can see that air fluid

2:34

level that we saw in the frontal view. The spinal canal looks well aligned.

2:42

The remainder of the lateral view is not really so helpful, for me at least.

2:50

So at this point,

2:51

we have a patient whose status post denting with air fluid levels that are

2:55

seen in the right lung with multiple lines and tubes like they're adequately placed.

3:01

I would want to get a better

3:03

evaluation of these air fluid levels to understand what's going on,

3:05

to understand whether or not we've got a loculated fluid collection

3:09

in the pleura, whether or not we have an empyema, whether or not there is, you know, some

3:13

degree of perforation related to the esophagus.

3:17

So we would recommend, at this point, a CT of the chest, ideally with contrast.

3:22

As it turns out, this patient did get a CT of the chest. Because of renal function,

3:27

he did not get contrast but we will do the best with what we've been given.

3:31

On a scout view, again, pretty helpful.

3:33

So you can see that air fluid level,

3:35

it's kind of shifted and changes in its appearance.

3:37

You can see really nicely the stent,

3:38

the number of drainage catheters and the pleural space, as we saw before.

3:43

So let's take a look at the soft tissues and then we'll go to the lungs.

3:47

Kind of moving through,

3:48

we see that the thyroid on the right is normal, but incidentally,

3:53

there is no left thyroid, so he's probably had that removed.

3:57

Take a look for any lymph nodes, and what

3:59

we do see are scattered nodes along the paratracheal area and the AP window.

4:06

But when we get down to the right posterior lobe, we do see this area of air

4:12

fluid level, which is what we're seeing on the radiograph.

4:14

We saw that on the scout.

4:16

And now the question is, where is this coming from?

4:18

So one of the questions was, do we think that there is a pleural

4:21

effusion and was it loculated? While looking at the left,

4:25

there does look like there's pleural fluid

4:27

here and it is not loculated, it's just layering with atelectatic changes there.

4:32

And then this area here on the right, looks like there is obviously air fluid level,

4:37

but it doesn't clearly look like a loculated effusion.

4:41

So we're going to have to put this

4:42

together and to understand what's happening.

4:44

So, moving from the bottom back, we see not only is there a feeding tube

4:51

in the stomach, we see the two chest tubes entering here.

4:57

There are actually three chest tubes entering here.

5:01

Coming across our stent, we see lots of little gas around the stent.

5:06

And this is the esophageal mass

5:08

that obviously the stent was probably placed to help alleviate.

5:12

But there's quite a bit of gas that seems like it's sitting around here.

5:16

And as we move up, it looks like it opens up into this large collection.

5:20

And so we'll look at this a little bit better on the lung windows,

5:23

but I'm wondering whether or not we're looking at a contained perforation

5:27

from the esophagus that's now sitting in the pleural space.

5:34

So, again, we're moving through a...

5:37

on the lung windows,

5:38

we see that there is an apical pneumothorax here on the right and you've got this

5:42

large lesion that is separate from the lung.

5:46

So the lung is actually sitting along here

5:48

pretty well, atelectatic and down.

5:52

We've got lung here, but there are no lung markings in this area.

5:55

So this is separate from lung and looks

5:57

like it's probably sitting in pleura, comes across and sits here.

6:01

But if we follow this back, the smaller foci of gas

6:07

kind of lead us to the mass and the area of where the stent took place.

6:13

So, again, here's, the air fluid level.

6:15

We do have lung that's kind of draped around here.

6:18

So this is not in lung.

6:20

It looks like it's displacing lung.

6:24

And then on the left side here,

6:26

we can see that there are a number of tubes that are placed.

6:30

There's no pneumothorax on that side.

6:33

We do have a tube that's placed on the right side with a small apical pneumo.

6:39

All right. So let's come back here and look at this

6:41

collection and see if we can put it all together.

6:43

So, stent here, crossing the GE junction,

6:46

large distal esophageal mass. At that mass site

6:49

and then around there, there's a lot of gas pockets that are seen.

6:54

And that gas pocket is in continuity

6:56

with this large air fluid level that is sitting in the pleural space,

7:00

but also displacing the parenchyma here, air fluid level we've talked about.

7:05

And this is related to an esophageal perforation.

7:09

At the core of this is probably

7:11

the esophageal cancer that's sitting there that the stent was placed.

7:15

This is a large collection that could contain, whether it's gastric contents or

7:20

stuff that's been taken PO and has moved through the esophagus,

7:23

not across the stent, but into this cavity.

7:26

It's not really clear, but we could have given contrast to see

7:31

what was actually extravasating and where things were extravasating from.

7:35

We did not give oral contrast, but we can recommend a fluoro study

7:38

with gastrografin to better understand the mechanics.

7:42

We didn't give IV contrast.

7:44

I think in this case, the patient's kidney function wouldn't sustain that.

7:48

And so some of the aspects of the nature

7:50

of the enhancement of this collection, we can't comment on.

7:54

But certainly given the history and the location of the lesion,

7:58

this would be compatible with an esophageal lesion that is perforated.

8:02

Contents has, you know, moved out of the esophagus either from the stomach

8:07

or from above and is now collecting in this potential space.

8:12

CT is helpful again for problem solving.

8:14

And just to kind of round this out,

8:16

we'll take a look at the same lesion on a couple of different viewpoints.

8:21

And so on the sagittal, we can see nicely here the stent across the GE junction,

8:28

and through the mass.

8:29

You can see lots of the gas that's sitting in and around and adjacent to that area.

8:33

The large air fluid level that is seen,

8:36

and that we've talked about quite significantly.

8:38

You can see the air bronchograms that are

8:41

being displaced in lung by the air fluid level.

8:47

This case does not have coronal views, but those would also be helpful.

8:51

And we'll just take one last look at this

8:53

with lung windows on, so you'll get a sense of what this may look like.

8:58

And so moving through,

9:01

again, from the left side into the area where the gas is forming,

9:09

the air fluid level, you see the lung anterior to that.

9:15

So one appearance of esophageal perforation, both on x-ray and on CT.