Radiographic, endoscopic, and computed tomography findings in a cat with complete esophageal obstruction caused by doxycycline-induced esophagitis

An Unusual Presentation of a Retained Esophageal Foreign Body

Adverse events of upper GI endoscopy

<p class="abstract"><strong>Background:</strong> Upper oesophageal stenosis is a well-recognised complication in the treatment of head and neck malignancies that can result in significant morbidity. Simple strictures can be managed by anterograde dilatation. Combined approach dilatation can overcome more complex and even complete stenosis.</p><p class="abstract"><strong>Methods:</strong> This was a retrospective analysis of prospectively gathered data for four patients who have had combined approach dilatation to overcome complete oesophageal stenosis. Outcomes determined using standardised swallowing outcome measurement tools. </p><p class="abstract"><strong>Results:</strong> A functional oesophageal lumen was restored in four patients with complete oesophageal stenosis, with a demonstrable improvement in validated swallowing outcome measures.</p><p class="abstract"><strong>Conclusions:</strong> Combined approach oesophageal dilatation can be safely and effectively utilised to overcome complete stenosis of the upper oesophagus secondary to radiotherapy/chemo-radiotherapy. Extending the indications for this procedure to post-surgical strictures is not advisable due to increased risk of serious complication.</p>

Sir, An intraorbital wooden foreign body is usually difficult to detect by conventional diagnostic techniques (Green et al. 1990; Yago et al. 1990). When such a body is not detected at an initial ophthalmological examination, it may be retained for a long time, until it is recognized through some ocular symptom or through orbital plain X-ray films, computed tomography (CT) or echography. Green et al. (1990) reported two cases of suspected intraorbital wood using CT scans, in both of which magnetic resonance imaging (MRI) clearly showed a well delineated, low intensity, intraorbital lesion. To our knowledge, few reports have revealed cases where a characteristic MRI finding has contradicted a negative CT examination and revealed a wooden foreign body that had been retained in the orbit for a couple of months. A 70-year-old woman was referred to our clinic for evaluation of right-sided eyeball pain and double vision. She had been injured in her right eye during a walk in the woods. She had gone to an eye clinic soon afterwards, and had been diagnosed with a right conjunctival laceration. After slit-lamp examination, when no foreign body was found, her lacerated conjunctiva was sutured. Her right ocular pain continued, and she went to another eye clinic. She was diagnosed with orbital cellulitis in the right eye, and underwent antibiotics infusion therapy on admission. Two months later her eye movement became worse, and the pain in her right eyeball recurred. She was then referred to the outpatient clinic at our hospital. At the initial ocular examination, the patient's visual acuity was 20/25 OU. Severely limited duction in the upper direction was observed in the right eye. A slit-lamp examination showed slight conjunctival hyperemia but no foreign body. Fundus examination revealed a retinal tear in the lower peripheral equator region of the right eye. Neither orbital plain X-ray films nor ocular echography revealed a foreign body. A CT scan of the right orbit showed a space-occupying lesion in the right lower part of the orbit (Fig. 1). The CT density suggested that this lesion was an almost homogeneous mass. However, T2-weighted MRI disclosed a well delineated, inner, stick-shaped lesion of high intensity, surrounded by an outer low intensity lesion (Fig. 2A, B). Thus, an orbital abscess in the right eye was strongly suspected at the time. CT scan showing a space-occupying lesion (SOL) in the right lower part of the orbit. The CT density indicates that the SOL is a homogeneous mass. Coronal image. T2-weighted MRI discloses a well delineated, inner, stick-shaped lesion of high intensity, surrounded by an outer low intensity lesion. Coronal (A) and sagittal (B) images. After photocoagulation therapy for the retinal tear in the right eye, an anterior orbitotomy was performed, and a 16-mm long, 4-mm diameter segment of wood with high water content was found; it was covered with thick outer granulation tissue. Scanning electron microscopy showed a characteristic constitution of wood (Fig. 3). Broad-spectrum antibiotic therapy was administered intravenously for 1 week. The patient completely recovered from the right ocular pain despite a mild disturbance in eye movement, and an MRI performed 4 weeks after surgery revealed no residual intraorbital wood. Scanning microscopic finding of the wooden foreign body removed from the right orbit. Because CT scanning may detect a wooden intraorbital foreign body as a linear dense structure surrounded by a soft tissue mass with density similar to that of muscle (Boncoeur-Martel et al. 2001), or as a lucent lesion with nearly the same density as air or fat (Specht et al. 1992), several papers support the usefulness of CT scans for detecting intraorbital foreign bodies. However, in a few reports CT scanning has been shown unable to identify intraorbital wood (Tate & Cupples 1981; Myllylä et al. 1987). Together, these findings suggest that the CT radiodensity of retained intraorbital wood is variable. Green et al. (1990) reported the first two known cases of intraorbital wood clearly detected by MRI. In those cases, CT scans revealed bone fracture as well as free air in the orbit. The patient in the present report differed from those in previous reports of an intraorbital wooden foreign body. Our case showed a space-occupying lesion but neither free air nor bone fracture in the right lower orbit on the CT scan, while the MRI clearly revealed a well delineated, stick-shaped lesion. In our case, the accident happened in a forest, and neither plain X-ray nor CT scanning showed any evidence of a metallic foreign body in the orbit. Thus, MRI was safe for our patient. The granulation tissue surrounding the wooden foreign body could not be distinguished from the moist foreign body by means of CT scanning. The percentage of water content may be different in each case reported so far. In conclusion, we believe that intraorbital wooden foreign bodies may be detected by MRI (Tsaloumas et al. 1998), even when CT findings are negative.

Valeur ajoutée du scanner préopératoire pour la dégénérescence cartilagineuse chez les patients présentant des lésions ostéochondrales du dôme du talus

Adverse events associated with EGD and EGD-related techniques

Introduction Esophageal strictures are usually a late manifestation of cancer irradiation. Complete obstructions are well known to occur. Treatment of such patients is complex, traditionally requiring complex surgery. We describe 3 cases, where luminal patency was re established using anterograde and retrograde endoscopic interventions. Case DescriptionsA 86 y/o man presented with progressive dysphagia after a h/o of SCC of the larynx that required a total laryngectomy followed by radiation. He was noted to have a complete esophageal stenosis. Using a anterograde (rigid) and a retrograde (flexible) endoscope, a needle was used to communicate across the obstruction under fluoroscopic guidance. A wire was then passed across the lumens creating a tract. Using the wire, serial dilations were performed followed by placement of an esophageal stent. Complete resolution of symptoms was achieved 3 months after the procedure. We describe 2 additional cases with similar outcomes. Discussion Complete esophageal obstruction occurs in a dose dependent manner after radiation exposure. Patient present with complete dysphagia. This technique has been previously described in multiple case series/reports. Review of the rendezvous procedure have reported a technical success of 95 % and clinical success in 81% patients. Tactile impression and transillumination usually allow for safe passage of the needle through the obstruction. The procedure success is limited in patients with obstructions greater than 3 cm. Adverse events have been reported in up to 20 % of these cases with only 1 mortality described in literature. Conclusion Bi-directional Endoscopic Rendezvous is a safe method for treatment of complete esophageal obstructions with good clinical outcomes.1783 Figure 1 No Caption available.

To evaluate the accuracy of spiral computed tomography (CT) in the noninvasive diagnosis of pulmonary embolism (PE). A prospective study was performed in 75 patients who were evaluated with spiral CT and pulmonary angiography of each lung to detect central PE; 25 of the patients also underwent ventilation-perfusion (V-P) scanning. Spiral CT scans were technically suboptimal in three patients. CT and angiographic findings were negative for PE in 25 patients; one patient had false-negative CT findings. Findings from both studies were positive in 39 patients. CT findings of 188 central emboli corresponded exactly to those of angiography. Ten emboli were depicted only on CT scans, whereas seven emboli were identified only on angiograms because of inadequate depiction of the pulmonary arteries in the plane of the CT scans (n = 5) or because of misinterpretation of CT findings (n = 2). The prospective sensitivity of CT was 91%, the specificity was 78%, the positive predictive value was 100%, and the negative predictive value was 89%. Technical failures (n = 3) and inconclusive CT findings (n = 7) were the major limitations of spiral CT. Spiral CT enabled accurate classification of PE in 16 patients with indeterminate (n = 7) and low (n = 9) probability of PE on V-P scans. CT demonstrated central PE in two patients with normal V-P scans. Spiral CT can reliably depict central PE and may be introduced into the classic diagnostic algorithms.

Objective To explore the types, clinical characteristics and treatment strategies of different complications caused by foreign bodies in digestive tract of children. Methods The clinical data of 104 cases of digestive tract foreign bodies were analyzed retrospectively from January 2010 to March 2017.The types, highest occurring age and extraction methods were analyzed.There were 66 boys and 38 girls with an age range of 6 to 168 months.Foreign bodies were located in upper esophagus (n=14), middle esophagus (n=12), lower esophageal (n=20), stomach (n=9), small intestine (n=15), ileocecal area (n=5), colon (n=22), rectum (n=6) and entire digestive tract (n=1). All cases were diagnosed by radiograph and computed tomography was added for problematic cases. Results The highest occurring age was 1 to 3 years old and accounted for approximately 45.2% (47/104). The shortest retention time of foreign bodies was 8 hours and the longest 3 months.The most common complications of foreign bodies were metallic (n=77), plant-based (n=17) and chemical (n=10). Foreign bodies were passed out on their own (n=86) or required surgery (n=18). No complications occurred during hospitalization.During a follow-up period of 2 months, all of them had an excellent recovery. Conclusions For children with foreign bodies in digestive tract, early diagnosis and individualized measures are recommended. Key words: Foreign bodies; Alimentary system; Child

An Unusual Case of Chest Pain and Pyrexia

Background: Osteochondral lesions of the talar dome (OLTs) involve the articular cartilage and subchondral bone. The subchondral bone plate (SBP) plays a crucial role in cartilage metabolism, and computed tomography (CT) can provide more precise information on subchondral bone. CT image prediction of the histological findings on OLT will be useful to determine the most appropriate therapeutic strategy. Purpose: To evaluate the unique features of the CT findings that relate to the condition of the articular cartilage in OLT. Study Design: Cohort study; Level of evidence, 3. Methods: Thirty ankles in 29 patients who had OLT with an osteochondral fragment were retrospectively reviewed. At surgery, the osteochondral fragment of 19 ankles could be preserved (preservation group) by fixation or drilling, and in the remaining 11 ankles, the osteochondral fragment was removed (excision group). Preoperative CT findings were compared between the 2 groups. Biopsies of the osteochondral fragment from 13 ankles were performed. The relationship between the CT and histological findings were evaluated. Results: The area of lesion in the preservation group was significantly larger than that in the excision group. The CT images of the lesion showed the rate of absorption of the SBP in the preservation group to be lower than that in the excision group. As for the lesion bed absorption, it was higher in the preservation group than in the excision group. All cases in the excision group showed bed sclerosis, compared with 42.1% in the preservation group. The specimens with disruption of the SBP exhibited cartilage degeneration and abundant chondrocyte cloning. OLT with absorption of the SBP on CT showed severe cartilage degeneration, while the remaining SBP on CT showed low-grade cartilage degeneration. Conclusion: This study shows the features of preoperative CT and histological findings in OLT with osteochondral fragments. The condition of the SBP affects the cartilage degeneration. CT findings provide important information for the determination of surgical treatment.

Complete esophageal stricture resulting from a neglected foreign body

This study evaluated success rates of surgical treatment of head and neck abscesses and draining tracts for suspected migrating vegetal foreign body and oropharyngeal penetrating injuries, and compared the outcomes according to whether a vegetal foreign body was identified in preoperative computed tomography (CT) examination. This retrospective study involved 39 dogs that underwent CT and subsequent surgical exploration of abscesses and/or draining tracts in the head and neck, in a single institution between 2010 and 2021. Recorded data included signalment, history, physical examination, CT and surgical findings. The postoperative follow-up period was at least 8 months. Cases were classified according to whether a foreign body was identified on CT or was only suspected because of the presence of cavities and/or draining tracts on CT. A vegetal foreign body was identified on CT in 11 of 39 cases and later confirmed at surgery in 10 cases. In 28 of 39 cases, a vegetal foreign body was not identified on CT, but in seven of these 28 cases it was found at surgery. Resolution of clinical signs was achieved in 11 of 11 cases when a vegetal foreign body was identified on CT and in 26 of 28 cases without a foreign body identified on CT. Two cases of recurrence were observed in animals in which no foreign body was detected. In this population of dogs undergoing surgery after preoperative CT scan, we observed resolution of clinical signs after a single surgical procedure in 95% of the cases. All animals in which a foreign body was identified were cured.

INTRODUCTION:Esophageal impaction in children is a medical emergency that needs an immediate medical attention. In the last years multiple objects have been detected and were removed endoscopically. In the last decade, Eosinophilic Esophagitis (EoE) has been associated with esophageal stenosis, leading to esophageal impaction with various objects including toys, food, coins and other.AIM:To determine the various objects and symptoms associated with impactions and to develop algorithm that guides Emergency Department Physicians and Primary care Providers when facing such problem in pediatric patient.MATERIAL AND METHODS:A retrospective chart review of all children referred to the pediatric gastroenterology service at Marshall University for FB impaction between 2000 and 2010 was performed. Foreign bodies treated by other specialties were excluded from this review. Clinical and demographic data were retrieved.RESULTS:A total of 291 charts with the diagnosis of foreign body reviewed of which only 126 met the inclusion criteria and considered for final calculation. Male/Female ratio and mean age were 1.17:1.0, and 3.65 ± 0.75 years, respectively. Time of impaction before ER evaluation was: < 24hrs in 75 patients, >24hrs in 17 and in 34 the time of ingestion was not known. Radiology was performed in 118 patients, of whom 1 had pneumo-mediastinum and 1 had pneumothorax. Endoscopic localization of the objects showed: 81- proximal, 23- middle esophagus, and 22- in the distal esophagus. The esophageal mucosa showed non-specific changes in 37 patients, 5 with EoE features, 1 patient with hiatal hernia, 1 patient with candidiasis, and in 5 pts had no mucosal description.CONCLUSION:Children with foreign body in the esophagus are commonly seen in our Hospital ER. Those children may harbor undiagnosed medical conditions that will need future therapy. Careful endoscopic assessment with mucosal biopsies is needed to diagnose those conditions earlier. Referral to a GI specialist may be warranted.

Computed tomography in blunt abdominal trauma: An analysis of clinical management and radiological findings