Today I am showing chest radiographs of a 81-years-old man with chest pain five years after left pneumonectomy for lung carcinoma
1. Broncho-pleural fistula
2. Intestinal hernia
4. None of the above
What do you see?
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
Click here for the answer
Findings: PA radiograph shows an opaque left hemithorax with a central cavity (A, black arrow) with an air-fluid level (A, red arrow). The splenic flexure of the colon is right below (A, yellow arrow). In the lateral view the central cavity has an inverted U-shape (B, black arrows) with two air-fluid levels (B, red arrows).
Unenhanced coronal and sagittal CT show that the central cavity is a dilated stomach (C and D, arrows), herniated through a large rent in the left hemidiaphragm (C and D, red arrows).
Final diagnosis: herniated stomach and colon through a wide diaphragmatic defect
I present this case to increase your awareness of an often forgotten subdiaphragmatic structure: the gastric bubble. Due to its air content, the gastric fornix is visible in most upright PA chest radiographs, and it can provide valuable information.
I have classified changes in the gastric bubble as follows:
4. Miscellaneous findings
An absent gastric bubble occurs in 10% of the normal population and 50% of patients with achalasia. Therefore, lack of a gastric bubble should prompt a review of the mediastinum to investigate a dilated esophagus (Fig. 1).
Remember that although an absent gastric bubble may suggest a diagnosis of achalasia, visible air in the fornix does not rule it out, as demonstrated in the case below (Fig. 2).
An absent air bubble may happen when the stomach is not in the left upper quadrant. This occurs in a rare congenital condition, abdominal heterotaxia, in which there is rotation only of the abdominal structures. In these cases, the gastric bubble is located under the right hemidiaphragm (Fig. 3).
Malpositioned gastric bubble occurs when the fornix is in an abnormal location. The most common cause is diaphragmatic hernia either through the esophageal hiatus (Fig. 4) or secondary to traumatic rupture of the diaphragm (Fig. 5).
In left hemithorax opacification, an abnormally located gastric bubble indicates the position of the hemidiaphragm and clarifies the etiology. Downward displacement indicates massive pleural effusion (Fig. 6), whereas elevation favors collapse of the whole lung (Fig. 7).
Gastric bubble displacement is also an indirect sign of an abdominal mass. The most common cause is splenomegaly, which pushes the aerated fornix towards the midline (Figs. 8 and 9).
Miscellaneous findings include visualization of masses outlined by air in the gastric bubble and occasionally air within the stomach wall. Masses in the gastric fornix may be due to carcinoma and other tumors, gastric varices, or postoperative deformities (Fig. 10) .
Air in the gastric wall may be seen after ingestion of corrosive substances or, more commonly, after forceful vomiting or secondary to an endoscopic procedure (Fig. 11).
Dilated stomach can occur alone or in generalized bowel dilatation. In the second case think of diabetes or mechanical pyloric obstruction (Fig. 12).
Follow Dr. Pepe’s advice:
1. Absent gastric bubble occurs in 50% of patients with achalasia.
2. Diaphragmatic hernias cause malposition of the gastric bubble.
3. Splenomegaly is the most common cause of displacement of the gastric bubble.
13 thoughts on “Dr. Pepe’s Diploma Casebook: CASE 131 – SOLVED”
Lossof volume of the left hemithorax. Surgical changes. Hidroneumothorax (with loculate fluid) probably because of broncopleural fistula, but the colon is localizated over the diaphragm (diaphragmatic hernia).
I think taht all the diagnosis are achievable (1 + 2 + 3).
Bronchopleural fistula and colon herniation. An empyema or pyopneumothorax cannot be excluded on plain films (answers 1 + 2 + 3)
Have a good day
I can see reduced left lung volume with ipsilateral mediastinal shift.
Bowel shadow seen occupying left hemithorax above diaphragm.
Large air fluid level seen in upper zone.
I would go with diagnosis of intestinal hernia.
Strangulation of large bowel hernia with ileus and Fluid level in dilated thoracal bowel loop -> intestinal hernia!
Colon shifted upwards in left hemithorax is obvious. Air fluid level in left hemithorax is in stomach which has also shifted upwards. So these are false leads that didn’t cause chest pain. As for other causes: degenerative changes on thoracic spine don’t explain the pain, but I see two paracardial nodules in the right lower zone, suspicious for contralateral tumor recurrence.
Remember that this patient is 81 years old. At that age, having pains anywhere is not that rare.
I know, because I am getting close 🙂
All of the above
I think, that it is broncho-pleural fistula. I see lucency with fluid level in left hemithorax, shifting of mediastinum to left side and patient is after pneumonectomy.. and aetiology of broncho-pleural fistula is common surgery of lung.
Due to left pneumonectomy left heithorax
– is filled by stomach and intestines because of left diaphragmal relaxation.
– There are no convincing signs of empyema or hydropneumothorax (due to broncho-pleural fistula).
– there is certain right lung hyperventilation with the next herniation at the Level of upper mediastinum and thus the shift of mediastinum slightly to the left
There are interstitial changings in the right lung parenchima – perhaps fibrotic changes but also the Inflammation can not be excluded
The lateral view shows local decreased transparancy at the Level of the anterior parts of the lower D10-11(?) vertebrae probably because of degenerative changes (bone excrescences) OR the round paravertebral lesion of the right lung which on PA veiw is obscured by the right atrium.
At the Level of the anterior part of the 4th rib closer to the right hilum the round opacity is seen (nodule? summation of the vessel silhouettes?)
The chest pain can be caused by postponed complications after the pneumoectomie
– gastric volvulus (stomach localised in the thorax cavity)
– cardiovascular disfunction
– esophageal motility disorders etcetc
2. Intestinal herniation: left colonic flexure & stomach
Regarding the diagnosis, I believe that the U-shape visible in the lateral view is indicative of stomach or a intestinal loop. in the second case we would see dilated loops in the abdomen, which are not present. Therefore, the most likely diagnosis is herniated stomach.
Congratulations to Rubia salman, who was the first to mention herniation.
Amazing article, Thank You for your work😊
Thank you. Glad you like it 🙂