Perforated oesophagus: review of twenty-eight consecutive cases.

Oesophageal perforation is a potentially lethal condition which requires early diagnosis and prompt surgical management. The radiological features in 28 patients with oesophageal perforation have been reviewed and correlated with the aetiology and site of perforation, underlying oesophageal abnormality and the time interval between occurrence and diagnosis. Twenty-five patients (89%) had detectable abnormalities on the chest radiograph. The commonest abnormalities were air in the cervical or mediastinal soft tissues and air or fluid in the pleural cavity. The factors influencing the different radiographic signs are discussed. Studies with a suitable contrast medium are necessary to show the site and extent of the perforation, the extent of any associated abscess cavity and the position of the perforation relative to any primary oesophageal disease. Of 26 patients who had a barium swallow a leak was demonstrated in 21 (81%). In the five patients in whom no leak was demonstrated the examination was performed more than 24 h after the perforation.     

Tension pyopneumothorax

Tension pyopneumothorax is a rare complication of pneumonia and subpleural abscess eroding into the pleural space. We present a case of tension pyopneumothorax in a drug addict. Successful treatment consisted of pleural drainage and parenteral antibiotics. The presence of an air–fluid level accompanying tension pneumothorax on chest radiograph should alert the physician to the possibility of this emergency condition.     

Chest ultrasound in the evaluation of complicated pneumonia in the ICU patients: Can be viable alternative to CT?

Objective

To compare ultrasound (US) and computed tomography (CT) for evaluating patients with complicated pneumonia admitted to the intensive care unit (ICU) to assess if US can be an alternative to CT.

Subjects and methods

We prospectively compared US and CT findings in 48 patients admitted to the ICU with complicated pneumonia with their final diagnosis at discharge. Images were evaluated for parenchymal findings (consolidation, necrosis, and abscess) and pleural findings (effusion, loculation or fibrin strands in the pleural fluid).

Results

US was similar to CT in the evaluation of parenchymal and pleural abnormalities except for two patients with consolidation and effusion, three patients with loculated effusion, one patient with pulmonary necrosis and another patient with lung abscess. US was superior to CT in detection of fibrin strands within pleural effusion.

Conclusion

Chest US provides an accurate evaluation of the pleural and parenchymal abnormalities associated with complicated pneumonia in the ICU patients. Considering that chest US is a bedside and avoids transportation of the patient outside ICU, free of radiation exposure and easily repeatable, chest US appears to be an attractive alternative to CT.     

Impact of CT in patients with sepsis of unknown origin.

PURPOSE: To evaluate the diagnostic relevance of CT in patients with sepsis of unknown origin. MATERIAL AND METHODS: Sixty-three consecutive intensive care patients with suspicion of an abscess and negative or inconclusive previous radiological examinations were included. CT was performed using the helical technique. A total of 45 abdominal and 38 chest examinations were evaluated. RESULTS: 5/38 examinations of the chest revealed the source of sepsis (pleural empyema 2, lung abscess 1, mediastinitis 1, retrosternal abscess 1). 7/45 abdominal CT examinations showed the source of sepsis (intraabdominal abscess 2, hepatic abscess 3, intestinal perforation 1, gangrenous colitis 1). CONCLUSION: CT is useful for the evaluation of patients with fever or sepsis without a known source. Due to the detection of a septic focus by CT, 19% of the patients in our study could be immediately referred to causal therapy as percutaneous drainage or surgery.     

Computed tomographic characteristics of pleural empyema

The computed tomographic characteristics of the pleural empyema were illustrated in three patients. A typical empyema is characterized by lower thorax location, oblong and round contour in cross-section, homogeneous content with or without air spaces or air-fluid levels, regularly thin wall opposing the chest wall (a rim sign), irregularly thick wall opposing the lung parenchyma, and smooth inner and outer margins. By application of such computed tomographic criteria, a pleural empyema can be readily distinguished from a peripheral lung abscess.     

儿童肺炎支原体性肺脓肿的CT表现（附12例分析）

目的:研究儿童肺炎支原体性肺脓肿的CT表现.方法:回顾性分析本院12例肺炎支原体性肺脓肿患儿的临床资料和胸部CT表现.结果:12例早期均表现为肺实质渗出性痛变,随病程进展出现液化坏死及大小、数目不等的空洞;11例为单侧肺叶受累,1例为两侧肺受累;6例右肺受累,5例左肺受累;2例合并有胸腔积液及胸膜增厚.随访4～18个月10例肺实变完全吸收,肺坏死及空洞消失;2例仍有局限性肺不张,呈纤维条索样改变;2例胸腔积液完全吸收.结论:儿童肺炎支原体性肺脓肿早期表现为肺实变,随病程进展出现液化坏死及空洞,可有胸腔积液及胸膜反应,经积极治疗大部分可吸收好转.     

Computed tomography of lung abscess and empyema

Lung abscess and empyema can often be distinguished on plain radiographs. Sometimes, oblique or decubitus views may be necessary in order to demonstrate the more specific conventional radiographic features--the shape of the lesion and its relationship to the chest wall. In seriously ill patients, special positioning may be impossible. CT may be easier to perform than special views in some ill patients. In many cases of suppurative disease, both lung and pleura may be involved, and pleural disease in the presence of lung disease is easily missed on plain radiographs. Furthermore, infections located at the periphery or at the apices of the thorax are difficult to define with conventional imaging. CT with cross-sectional images and unequalled density resolution delineates the lung-pleura interface and the periphery and apices of the lung. With CT, lung abscess and empyema show statistically significant differences in shape--round (abscess) or lenticular (empyema); the presence of separation of pleural layers (empyema); the presence of lung compression (empyema); the presence of acute (abscess) or obtuse (empyema) chest wall angles; and wall characteristics--thick, nonuniform, and irregular (abscess) or thin, uniform, and smooth (empyema). Few lesions demonstrate all of these features; however, sufficient information may be obtained from CT to permit a confident diagnosis of lung abscess or empyema. Thus, CT helps in the evaluation of suppurative diseases. CT provides diagnostic information not available from conventional radiographs in 47 per cent of cases, and in 34 per cent of cases, CT gives more accurate delineation of the extent of disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

US in the diagnosis of pediatric chest diseases.

Most pediatric chest diseases are adequately evaluated with chest radiography. However, when chest radiography does not allow identification of the location and nature of an area of increased opacity, ultrasonography (US) can help establish the diagnosis. US may be helpful in evaluation of persistent or unusual areas of increased opacity in the peripheral lung, pleural abnormalities, and mediastinal widening; US is particularly useful in patients with complete opacification of a hemithorax at radiography. In cases of pulmonary parenchymal lesions, identification of air or fluid bronchograms at US and of pulmonary vessels at color flow imaging is useful for differentiating pulmonary consolidation or atelectasis from lung masses and pleural lesions. US allows characterization of pleural fluid collections as simple, complicated, or fibroadhesive, which is important information for planning thoracentesis or thoracotomy. Computed tomography and magnetic resonance imaging are superior to US in evaluation of the mediastinum, but US is a reasonable alternative in certain situations (eg, to avoid unnecessary investigation of a normal thymus simulating a mediastinal mass). In cases of chest wall lesions, US may enable localization of the site of origin to soft tissues or an extrapleural intrathoracic location. Osseous involvement, particularly rib involvement, is easily evaluated with US.     

Pneumonia in the immunocompetent patient

Pneumonia is an acute inflammation of the lower respiratory tract. Lower respiratory tract infection is a major cause of mortality worldwide. Pneumonia is most common at the extremes of life. Predisposing factors in children include an under-developed immune system together with other factors, such as malnutrition and over-crowding. In adults, tobacco smoking is the single most important preventable risk factor. The commonest infecting organisms in children are respiratory viruses and Streptoccocus pneumoniae. In adults, pneumonia can be broadly classified, on the basis of chest radiographic appearance, into lobar pneumonia, bronchopneumonia and pneumonia producing an interstitial pattern. Lobar pneumonia is most commonly associated with community acquired pneumonia, bronchopneumonia with hospital acquired infection and an interstitial pattern with the so called atypical pneumonias, which can be caused by viruses or organisms such as Mycoplasma pneumoniae. Most cases of pneumonia can be managed with chest radiographs as the only form of imaging, but CT can detect pneumonia not visible on the chest radiograph and may be of value, particularly in the hospital setting. Complications of pneumonia include pleural effusion, empyema and lung abscess. The chest radiograph may initially indicate an effusion but ultrasound is more sensitive, allows characterisation in some cases and can guide catheter placement for drainage. CT can also be used to characterise and estimate the extent of pleural disease. Most lung abscesses respond to medical therapy, with surgery and image guided catheter drainage serving as options for those cases who do not respond.     

The spleen-lung interface as diagnostic information.

Left anterior, lateral, and posterior views on 50 consecutive RES-lung scams were examined. Normal patients had continuity of activity between the left lung and the spleen on all three views. Patients with subphrenic abscess or large left pleural effusions showed no continuity between lung and spleen activity on any view, while other abnormalities, most commonly cardiomegaly, accounted for lack of lung-spleen continuity on the anterior view only. It is suggested that in all combined RES-lung studies, the left side be examined as well as the right for abnormalities adjacent to the left diaphragm.     

Problems in the application of ultrasonography for the evaluation of pleural opacities

Fifty-nine patients with pleural abnormalities on chest radiographs were evaluated by B-mode ultrasonography; the lesions were categorized as echo-free or complex. Echo-free lesions included pleural fluid collections, and abnormalities which did not yield "fluid" through an appropriately positioned large caliber needle. "Complex appearing" lesions yielded fluid through a needle in all cases. Ultrasonography could not accurately predict which lesions were amenable to successful thoracocentesis. Findings from recent radiographs and clinical history must be known when the ultrasonographic findings in patients with chest abnormalities are interpreted.     

CT demonstration of empyema necessitatis

Empyema necessitatis is a collection of fluid that has, by direct extension from the pleural cavity, penetrated the thoracic wall to form a mass in the extrapleural soft tissues of the chest wall. This is a rare condition and usually is associated with tuberculous effusion but may be associated with malignancy, blastomycosis, actinomycosis, and may even follow thoracentesis.     

Hemoptysis demonstrated on Tc99m-sulfur colloid scanning: a rare complication of amoebic liver abscess

We report the finding of bleeding into right lung from a ruptured amoebic liver abscess. A 25-year-old male presented with pain in the right lower chest and cough associated with expectoration of chocolate-colored sputum. Radiographs of chest showed right-sided pleural effusion. Serial images of Tc99m-sulfur colloid study revealed progressive accumulation of radiotracer in the upper photopenic area extending into the right lung region suggestive of active bleeding from the abscess cavity.     

胆固醇性胸膜腔积液的X线特征（附6例报告并文献复习）

目的探讨胆固醇性胸腔积液的X线特征及诊断要点。方法回顾性分析经检查胸水证实为胆固醇性胸腔积液6例患者的X线胸片。结果6例均为左侧大量胸腔积液,压片检查均见典型胆固醇结晶。4例X胸片上可见胸膜呈蛋壳样钙化。1例手术见脏壁层胸膜均有钙化。结论胸膜表面蛋壳样钙化是本病的X线特征。确诊需做胸水检验。     

Epithelioid hemangioendothelioma of the pleura: clinical and radiologic features

OBJECTIVE: The purpose of our study was to describe the clinical and radiologic features of epithelioid hemangioendothelioma of the pleura. CONCLUSION: Pleural epithelioid hemangioendothelioma is an uncommon malignancy that typically affects older men, who present with chest pain and dyspnea. This lesion manifests on chest radiographs and CT scans with unilateral pleural fluid and nodular pleural thickening and appears similar to diffuse pleural carcinomatosis or mesothelioma.     

The extrapleural fat in empyema: CT appearance

Pleural empyema can be accompanied by changes in the adjacent chest wall. We examined the chest wall on computed tomographic scans in 24 patients with pleural effusions. Eighteen patients had pleural empyema and six had transudative effusions. Of the 18 empyema patients, 13 had abnormally high attenuation in the extrapleural tissues. In 12 of these 13, the high attenuation was probably caused by reaction to the pleural infection. In two, it was probably caused by haematoma (one patient had haematoma and empyema). In five patients there was either no clear abnormality in the extrapleural space or an insufficient amount of fat to permit detection of an abnormality, or the parietal pleura could not be distinguished from the pleural fluid because intravenous contrast medium was not given. Of the six patients with proven transudative pleural effusions, all had extrapleural fat which appeared normal. Abnormally high attenuation in the extrapleural tissues can be expected to accompany exudative pleural effusion, particularly empyema, but not transudative effusion.     

Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: Is computed tomography more accurate than chest radiograph?

OBJECTIVE: The aim of this study was to compare the accuracy between computed tomography (CT) and frontal chest radiography in the diagnosis of malpositioned chest tubes (MCT). MATERIALS AND METHODS: CT scans positive for MCT between March 2000 and March 2004 were reviewed. Two radiologists assessed for intra- and extrathoracic locations of MCT in CT studies. Two physicians who were blinded to the results of CT scans assessed the frontal chest radiographs for location of chest tubes, within the pleural space or outside pleural space. The results of CT were then compared with the results of frontal chest radiographs. Medical records were also reviewed for function of the chest tubes and any complications induced by MCT. RESULTS: CT revealed 28 MCT among the 76 chest tubes that were placed in 54 patients. Among the 28 MCT detected by CT, 23 tubes were in the intrathoracic location (20 intraparenchymal; 3 intrafissural) and 5 tubes were in the extrathoracic location (4 in mediastinum; 1 in chest wall). Frontal chest radiographs only revealed six MCT. Among 28 MCT, 16 sufficient, 8 insufficient, and 4 indeterminate functions of the chest tubes were noted from medical charts. One patient complicated with lung abscess, four patients had suffered pleural empyema, and one patient suffered active lung parenchymal bleeding, resulting from MCT. CONCLUSIONS: CT is more accurate than chest radiograph for the diagnosis of MCT. For selected patients with inadequacy drainage of the tubes and when chest radiograph is noncontributory, CT scan is recommended to clarify the exact location of chest tubes.     

Sonography of malignant pleural effusion

Two hundred and ten patients with exudative pleural effusion were studied by ultrasound for sonographic signs of pleural carcinomatosis. Images were evaluated for echoes within the fluid, septations, sheet-like or nodular pleural masses, and associated lesions of the lung. Our results showed that sonographic findings of echogenic or septated fluid were unspecific for malignancy. Only the evidence of pleural masses was characteristic of malignant effusion. Ultrasound of the chest should therefore be carried out before invasive diagnostic procedures are planned. Received 31 May 1995; Revision received 12 September 1996; Accepted 14 January 1997     

Pleural tuberculosis evaluated by computed tomography

Twenty-four cases of pleural tuberculosis (20 active and 4 inactive) were studied with computed tomography (CT). In 14 patients with proved acute tuberculous pleurisy, CT improved diagnostic accuracy by demonstrating small areas of cavitation not apparent on the chest radiograph and by detecting or confirming lymphadenopathy. In 10 patients with chronic tuberculous pleural disease, CT differentiated active from inactive infection by detecting a collection of fluid within the pleural rind. In both groups, CT also demonstrated complications such as bronchopleural fistula and involvement of the chest wall. CT can be beneficial in such cases because of its ability to show the pleural surfaces in transverse section, discriminate parenchymal from pleural disease, and quantify tissue density.     

Large unilateral chest tumors in children

When large unilateral chest tumors are hidden by pleural fluid collections, or when there is a completely radiopaque hemithorax, ultrasonography is an efficient means of identifying and characterizing a mass. Narrowing of the carinal angle in patients with mediastinal shift is helpful in identifying large intrathoracic tumors that could be mistaken for, or hidden by, large pleural effusions. Of 11 large tumors in children, seven were Ewing's sarcomas, two were metastatic sarcomas, one was a lymphoma, and one was an undifferentiated small cell tumor of unknown origin. The rib lesions of Ewing's sarcoma were seen clearly on chest radiographs in all patients with that disease.