I am starting a new section named “Big little findings”. The aim is to emphasize the importance of discovering subtle findings that should not be missed. They are easily seen if you know what to look for.
Today I’m showing preoperative chest radiographs of a 69-year-old man with bladder carcinoma.
What do you see?
Click here to see the answer
Findings: the most important feature is a negative finding: absence of air in the gastric fornix (A, circle). Although this is sometimes seen in healthy persons, it is more frequent in distal esophageal obstruction. A careful look discovers that the left mediastinum has a double contour, actually the left wall of the dilated esophagus (A, blue arrow) and the descending aorta (A, red arrow). There is bulging of the right paraesophageal line (A, yellow arrow). A dilated air-filled upper esophagus is visible in the lateral view (B, arrows).
The findings are typical of lower esophageal obstruction with dilatation of the esophagus. The double contour of the left mediastinum is better seen in the cone down view (C, arrows) and confirmed with CT (D, arrows).
The air-filled dilated esophagus in the lateral view (E, arrows) is confirmed with sagittal CT (F, arrows) (T= trachea).
Final diagnosis: unsuspected esophageal achalasia
To my eternal shame, I confess that when I read the initial radiographs I overlooked the findings (nobody’s perfect!). Achalasia was discovered in a routine follow-up CT taken one year later. I redeemed myself in a subsequent pre-op PA radiograph of the patient, in which I saw a double contour of the descending aorta (A and B, red and blue arrows) and bulging of the paraesophageal line (A and B, yellow arrows). I missed the absent air in the gastric fornix, again!
Esophageal achalasia is not an uncommon condition, and early stages can be suspected in the chest radiograph if we pay attention to the telltale signs. Note that these signs are not specific for achalasia and can be secondary to any obstructive process of the distal esophagus. The most revealing findings are:
Absent gastric bubble
Displaced lower mediastinal lines
Air-fluid level in the mediastinum
ABSENT GASTRIC BUBBLE
Occurs in about 10% of the normal population and 50% of achalasia patients, and is due to failure of swallowed air to cross the distal esophageal sphincter. It is a negative finding and therefore, difficult to recognize. When it is detected, we should examine the lower mediastinum, looking for signs of esophageal dilatation (Fig. 1).
DISPLACED LOWER MEDIASTINAL LINES
A dilated esophagus displaces the paraesophageal line toward the right, making it convex. The left wall of the esophagus moves outward, and is sometimes seen as a double contour with the descending aorta (Figs. 2 and 3). Convexity of the paraesophageal line is the most reliable sign and the easiest to detect.
AIR-FLUID LEVEL IN MEDIASTINUM
Excluding hiatal hernia, an air-fluid level in the mediastinum is usually located in the esophagus. It is seen as a straight horizontal line in the middle/upper mediastinum. It is usually related to esophageal obstruction of any cause, the most common being achalasia. Discovery of an air-fluid level should lead us to investigate other signs of esophageal dilatation (Figs. 4 and 5).
Aspiration pneumonia is a complication of achalasia. I’m showing two cases in which the signs mentioned helped to suggest the correct diagnosis (Figs. 6 and 7).
55-year-old man with pancreatic carcinoma and known achalasia who presented with marked cough. Chest radiographs show bilateral airspace infiltrates. In the PA view there is also dilatation of the upper esophagus (A, white arrows) with an air-fluid level (A, red arrow). The lateral view shows a retrocardiac mass (B, white arrow), suggestive of a dilated lower esophagus. The trachea is displaced forward (B, red arrow). These signs were overlooked by the radiologist, whose diagnosis was widespread pneumonia.
Coronal CT demonstrates widespread air-space disease. It also shows a dilated esophagus (C, arrow). Axial CT images confirm dilatation of the esophagus, which is full of residue
(D and E, arrows).
Final diagnosis: esophageal achalasia with secondary aspiration pneumonia.
This an old case of a 27-year-old woman with a chronic RUL opacity suspected to be TB (disregard the opacities in both middle lung fields, caused by superimposed breast implants).
PA chest radiograph shows an opacity in the right upper lobe (A, circle). A right paramediastinal line extends from top to bottom (A, arrows). The lateral view shows anterior displacement of the trachea by a tubular structure (B, arrows), which occupies the upper and middle mediastinum. Both findings suggest a dilated esophagus.
Barium swallow confirms the dilated esophagus, secondary to narrowing at the esophagogastric junction (insert, arrow). Considering the age of the patient, achalasia with aspiration pneumonia was the most likely diagnosis, confirmed later.
(Remember that aspiration pneumonia goes to the right upper lobe when the patient is recumbent at night).
Follow Dr. Pepe’s advice:
Subtle findings of distal esophageal obstruction (achalasia) that should not be overlooked:
1. Absent gastric bubble
2. Displaced lower mediastinal lines
3. Air-fluid level in mediastinum
25 thoughts on “Dr. Pepe’s Diploma Casebook 166 – Big little findings – SOLVED”
In my opinion, there are some visible interstitial changes more in the right lung parenchyma, with tiny miliary nodules and more seen in S6 projection on lateral view. DD aging lung
First I also thought about dilatated esophagus but than, in my opinion, I found the line of its posterior wall. So decided – no dilatation.
What I suggested also – that the walls of esophagus could be thickened.
– lateral shows dilated esophagus
– absent gastric bubble
Conclusion: pseudo-/achalasia, needs further evaluation in CT or fluoroscopy with barium swallow
No gastic bubble, the oesophagus is dilated, Naclerio’s V sign on the left side…Boerhave with pneumomediastinum?
Not discussing most of your findings but remember this a preop radiograph, which should not be compatible with Boerhave.
Azygoesophageal line looks more or less normal. Posterior junction line (or is it the left paraspinal line?) seems to be thickened. Slightly thickened retrotracheal stripe on the lateral view.
There appears linear retro cardiac density with lateral displacement of left paraspinal line.Differential includes any pathology related to descending aorta.In this particular case, May be any complications related to intravesical BCG therapy.
….Gentilie PROF….. a me sembra di vedere , in AP, a dx, a livello paramediastinico alto, un sottile tubicino, rx’opaco, che potrebbe essere un pezzo di catetere venoso migrato dalla sue sede originaria….
Good observation! But is has no relationship with the main findings 🙂
Double line in the left paraspinal area (one is the descending aorta). In the lateral x-ray there is anythig wrong. A would recommend a CT-scan
In the lateral view there is something wrong. Look again 🙂
Are the esophageal walls thickened?
Is the esophagus dilated?
Aneurysm ascending aorta
The patient is 69 y.o. and is entitled to an elongated aorta 🙂
The patient is 69 years old and is entitled to an elongated aorta 🙂
Mediastinal widening to the right. I would suggest a CT for further investigation.
Given the hint of a certain abnormality on the lateral view…
a. There is an oblique line crossing the posterior elements of an upper thoracic vertebra which may correspond to the finding mentioned by the Italian colleague.
b. I see an oval lucency superimposed between the left pulmonary artery and the aorta which could be a posteriorly displaced bronchus.
The line that you mentioned is too subtle. The important findings are more obvious. Look again 🙂
Soft tissue density in the anterior mediastinum (anterior to aorta and retrosternal space)
…Esimio PROF. Il sottile tubicino sembra infilarsi in trachea, anteriormente….
In my opinion: Aneurysm ascending aorta
The answer is: achalasia with dilated esophagus. See the answer posted today. Congratulations to Rafał, who made the diagnosis.