Diagnostic Radiology
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toms, the patient had been drinking heavily. There was a history of duodenal ulcer and heinatemesis. On admission the patient was diaphoretic with a blood pressure of 58/0, pulse of 120/minute, temperature of 99°F and respiratory rate of 24/minute. The abdomen was flat and diffusely tender; there were no bowel sounds. Stool examination was guaiac negative. The white blood count was 15,000/mm3 and the hematocrit was 49%. Other laboratory tests were normal. Hypotension and a hematocrit of 49 % suggested hemoconcentration. Despite 5 IU of plasmanate, however, the patient's hematocrit rose to 60%. Thirteen more units were required to bring the hematocrit down to 47 %. The next morning, the patient's abdomen was grossly distended and rigid. A barium swallow showed a filling defect in the distal esophagus with high grade obstruction. Overhanging margins were demonstrated on all films in all projections (Fig. 1). In view of the patient's history of alcohol ingestion and vomiting, esophageal laceration and intramural hemafoma were suggested and exploratory surgery was performed. When the tense peritoneal cavity was incised, a necrotic small bowel and bloody ascites were immediately apparent. A small bowel volvulus was found. The necrotic bowel from the midjejunum to the ileocecal valve was resected. Because of the roentgen findings, the patient's hiatus was surgically explored and simultaneous endoscopy was performed. The esophagus was completely normal. Subsequent upper gastrointestinal series two weeks later demonstrated no esophageal abnormality (Fig. 2).
Esophageal Obstruction Associated with Small Bowel Volvulus 1 Marc Berger, M.D., and Francis J. Scholz, M.D.2
Small bowel volvulus, abdominal distension, and prolapse of the gastric mucosa led to esophageal obstruction in a 34-year-old alcoholic. INDEX TERMS: Abdomen, abnormalities. Alcoholism. Esophagus, obstruction • Gastrointestinal tract, mucosa
Radiology 119:39-40, April 1976
• functional disorders, inflammatory strictures, and benign and malignant neoplasms are well known as causes of obstruction to the esophagus (2, 3, 7, 8) but there are lesions that produce obstruction without causing esophageal disease (5, 6, 7, 9). A patient with total obstruction of the distal esophagus due to retrograde prolapse of the gastric mucosa associated with small bowel volvulus is described below.
C
ONGENITAL LESIONS,
CASE REPORT A 34-year-old male alcoholic presented after 24 hours of severe epigastric pain. There was associated vomiting but no nausea, hematemesis or dysphagia. Twelve hours prior to the onset of symp-
Fig. 1. Upper gastrointestinal series immediately prior to surgery. A small amount of barium intermittently appeared in the central "core" but none entered the stomach. All films showed overhanging margins. Fig. 2. Upper gastrointestinal series two weeks after surgery. The esophagus is normal. 1 From the Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, Boston, Mass. Accepted for publication in October 1975. Supported in part by USPHS grant GM 18674. 2 Present address: Department of Radiology, Lahey Clinic Foundation, Boston, Mass. shan
39
40
MARC BERGER AND FRANCIS
DISCUSSION Most often distal esophageal obstruction, as seen in this patient, represents adenocarcinoma of the gastric cardia with extension into the esophagus or a primary esophageal malignancy. Food lodged just proximal to a region of stricture may also result in the appearance of an intraluminal mass. Less commonly, intramural hemorrhage may lead to an obstructing lesion. The region of laceration is most often near the gastroesophageal junction where the viscus is less mobile (8). Gastric mucosal prolapse has been promoted by placing the patient prone on a bolster or by performing Valsalva maneuvers (1, 4, 10). Both these maneuvers raise intra-abdominal pressure. The patient in our case developed acute, massive abdominal distension secondary to small bowel volvulus. The distension probably led to prolapse of the gastric mucosa. Decompression of the abdomen at the time of surgery resulted in spontaneous reduction of the prolapsed gastric mucosa.
J.
SCHOLZ
volving the esophagus. J Thorac Cardiovasc Surg 68:148-158, Jul 1974 3. Kolodny M, Schrader ZR. Rubin W, et al: Esophageal achalasia probably due to gastric carcinoma. Ann Intern Med 69:569573, Sep 1968 4. Rudnick JP. Ferrucci JT, Eaton SB Jr, et al: Esophageal pseudotumor: retrograde proiapse of gastric mucosa into the esophagus. Am J RoentgenoI115:253-256. Jun 1972 5. Sakiyalak P, Bellon EM, David P, et al: Esophageal obstruction due to saccular aneurysm of the distal thoracic aorta. J Thorac Cardiovasc Surg 64:959-962, Dec 1972 6. Strang C, Walton IN: Carcinoma of the body and tail of the pancreas. Ann Intern Med 39:15-37, Jul 1953 7. Sullivan MA: Masses of the distal esophagus and proximal stomach. South Med J 65:785-790, Jun 1972 8. Thompson NW, Ernst CB, Fry WJ: The spectrum of emetogenic injury to the esophagus and stomach. Am J Surg 113:13-26. Jan 1967 9. Ward P: Pulmonary and oesophageal presentations of pancreatic carcinoma. Br J Radiol 37:27-33, Jan 1964 10. Wells J: Herniation of gastric mucosa into the esophagus. Am J Roentgenol 58: 194-195, Aug 1947
REFERENCES 1. Blum SO, Weiss A, Weiselberg HM, et al: Retrograde prolapse of gastric mucosa into the esophagus. Gastroenterology 41: 408-411, Oct 1971 2. Harkins JR, Cole FN, Attar S, et al: Adenocarcinoma in-
April 1976
Department of Radiology Harvard Medical School 25 Shattuck Street Boston, Mass. 02115
•
toms, the patient had been drinking heavily. There was a history of duodenal ulcer and heinatemesis. On admission the patient was diaphoretic with a blood pressure of 58/0, pulse of 120/minute, temperature of 99°F and respiratory rate of 24/minute. The abdomen was flat and diffusely tender; there were no bowel sounds. Stool examination was guaiac negative. The white blood count was 15,000/mm3 and the hematocrit was 49%. Other laboratory tests were normal. Hypotension and a hematocrit of 49 % suggested hemoconcentration. Despite 5 IU of plasmanate, however, the patient's hematocrit rose to 60%. Thirteen more units were required to bring the hematocrit down to 47 %. The next morning, the patient's abdomen was grossly distended and rigid. A barium swallow showed a filling defect in the distal esophagus with high grade obstruction. Overhanging margins were demonstrated on all films in all projections (Fig. 1). In view of the patient's history of alcohol ingestion and vomiting, esophageal laceration and intramural hemafoma were suggested and exploratory surgery was performed. When the tense peritoneal cavity was incised, a necrotic small bowel and bloody ascites were immediately apparent. A small bowel volvulus was found. The necrotic bowel from the midjejunum to the ileocecal valve was resected. Because of the roentgen findings, the patient's hiatus was surgically explored and simultaneous endoscopy was performed. The esophagus was completely normal. Subsequent upper gastrointestinal series two weeks later demonstrated no esophageal abnormality (Fig. 2).
Esophageal Obstruction Associated with Small Bowel Volvulus 1 Marc Berger, M.D., and Francis J. Scholz, M.D.2
Small bowel volvulus, abdominal distension, and prolapse of the gastric mucosa led to esophageal obstruction in a 34-year-old alcoholic. INDEX TERMS: Abdomen, abnormalities. Alcoholism. Esophagus, obstruction • Gastrointestinal tract, mucosa
Radiology 119:39-40, April 1976
• functional disorders, inflammatory strictures, and benign and malignant neoplasms are well known as causes of obstruction to the esophagus (2, 3, 7, 8) but there are lesions that produce obstruction without causing esophageal disease (5, 6, 7, 9). A patient with total obstruction of the distal esophagus due to retrograde prolapse of the gastric mucosa associated with small bowel volvulus is described below.
C
ONGENITAL LESIONS,
CASE REPORT A 34-year-old male alcoholic presented after 24 hours of severe epigastric pain. There was associated vomiting but no nausea, hematemesis or dysphagia. Twelve hours prior to the onset of symp-
Fig. 1. Upper gastrointestinal series immediately prior to surgery. A small amount of barium intermittently appeared in the central "core" but none entered the stomach. All films showed overhanging margins. Fig. 2. Upper gastrointestinal series two weeks after surgery. The esophagus is normal. 1 From the Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, Boston, Mass. Accepted for publication in October 1975. Supported in part by USPHS grant GM 18674. 2 Present address: Department of Radiology, Lahey Clinic Foundation, Boston, Mass. shan
39
40
MARC BERGER AND FRANCIS
DISCUSSION Most often distal esophageal obstruction, as seen in this patient, represents adenocarcinoma of the gastric cardia with extension into the esophagus or a primary esophageal malignancy. Food lodged just proximal to a region of stricture may also result in the appearance of an intraluminal mass. Less commonly, intramural hemorrhage may lead to an obstructing lesion. The region of laceration is most often near the gastroesophageal junction where the viscus is less mobile (8). Gastric mucosal prolapse has been promoted by placing the patient prone on a bolster or by performing Valsalva maneuvers (1, 4, 10). Both these maneuvers raise intra-abdominal pressure. The patient in our case developed acute, massive abdominal distension secondary to small bowel volvulus. The distension probably led to prolapse of the gastric mucosa. Decompression of the abdomen at the time of surgery resulted in spontaneous reduction of the prolapsed gastric mucosa.
J.
SCHOLZ
volving the esophagus. J Thorac Cardiovasc Surg 68:148-158, Jul 1974 3. Kolodny M, Schrader ZR. Rubin W, et al: Esophageal achalasia probably due to gastric carcinoma. Ann Intern Med 69:569573, Sep 1968 4. Rudnick JP. Ferrucci JT, Eaton SB Jr, et al: Esophageal pseudotumor: retrograde proiapse of gastric mucosa into the esophagus. Am J RoentgenoI115:253-256. Jun 1972 5. Sakiyalak P, Bellon EM, David P, et al: Esophageal obstruction due to saccular aneurysm of the distal thoracic aorta. J Thorac Cardiovasc Surg 64:959-962, Dec 1972 6. Strang C, Walton IN: Carcinoma of the body and tail of the pancreas. Ann Intern Med 39:15-37, Jul 1953 7. Sullivan MA: Masses of the distal esophagus and proximal stomach. South Med J 65:785-790, Jun 1972 8. Thompson NW, Ernst CB, Fry WJ: The spectrum of emetogenic injury to the esophagus and stomach. Am J Surg 113:13-26. Jan 1967 9. Ward P: Pulmonary and oesophageal presentations of pancreatic carcinoma. Br J Radiol 37:27-33, Jan 1964 10. Wells J: Herniation of gastric mucosa into the esophagus. Am J Roentgenol 58: 194-195, Aug 1947
REFERENCES 1. Blum SO, Weiss A, Weiselberg HM, et al: Retrograde prolapse of gastric mucosa into the esophagus. Gastroenterology 41: 408-411, Oct 1971 2. Harkins JR, Cole FN, Attar S, et al: Adenocarcinoma in-
April 1976
Department of Radiology Harvard Medical School 25 Shattuck Street Boston, Mass. 02115
