1991, The British Journal of Radiology, 64, 1060-1061 radiological or ultrasonographic examination. The distribution and appearance of this calcification, and its presence or absence at other sites, may enable a diagnosis to be made. The two cases presented do not fit into previously described categories. We propose an additional cause of neonatal calcification; that is dystrophic calcification arising in a subcapsular haematoma. Both of our cases presented with hydrops fetalis and had a chromosomal abnormality. The significance of these findings in the pathogenesis of hepatic calcification is uncertain. We would, however, suggest that the anaemia found in hydrops fetalis stimulates hepatic haemopoiesis and this, in turn, renders the liver more susceptible to subcapsular haematoma formation which subsequently calcifies. Neonatal hepatic calcification and hydrops fetalis may, therefore, be a new association.
Case reports BLANC, W. A., BERDON, W. E., BAKER, D. H. & WIGGER, H. J.,
1967. Calcified portal vein thromboemboli in newborn and stillborn infants. Radiology, 88, 287-292. CREMIN, B. J. & Nuss, D., 1974. Calcified hepatoblastoma in a newborn. Journal of Pediatric Surgery, 9, 913-915. FOROUHAR, F., 1982. Meconium peritonitis: pathology, evolution and diagnosis. American Journal of Clinical Pathology, 78, 208-213. FRIEDMAN, A. P., HALLER, J. O., BOYER, B. & COOPER, R.,
1981. Calcified portal vein thromboemboli in infants: radiography and ultrasonography. Radiology, 140, 381-382. LINCE, D. M., PRETORIUS, D. H., MANCO-JOHNSON, M. L., MANCHESTER, D. & CLEWELL, W. H., 1985. The clinical
significance of increased echogenicity in the fetal abdomen. American Journal of Roentgenology, 145, 683-686. Moss, A. A., CLARK, R. E., PALUBINSKAS, A. J. & DELORIMIER,
A. A., 1971. Angiographic appearance of benign and malignant hepatic tumours in infants and children. American Journal of Roentgenology, 113, 61-69. NGUYEN, D. L. & LEONARD, J. C , 1986. Ischaemic hepatic
References ABLOW, R. C. & EFFMAN, E. L., 1972. Hepatic calcification
associated with umbilical vein catheterisation in the newborn infant. American Journal of Roentgenology, 114, 380-385.
necrosis: A cause of fetal liver calcification. American Journal of Roentgenology, 147, 596-597. SHACKELFORD, G. D. & KIRKS, D. R., 1977. Neonatal hepatic
calcification secondary Radiology, 122, 753-757.
to
transplacental
infection.
Oesophageal ruptures complicating balloon dilatation of strictures: a report of two cases By B. M u c c i , M B , ChB, FRCR Department of Diagnostic Radiology, West Cumberland Hospital, Whitehaven, Cumbria CA28 8JG, UK
{Received February 1991 and in revised form April 1991) Keywords: Oesophageal perforation, Balloon dilatation
Balloon dilatation of upper gastro-intestinal tract strictures is accepted as a safe and effective method of dealing with lesions of varying aetiology. Perforation of the oesophagus is a recognized, but rare complication. Two such cases are described and their management is discussed. Case 1 A 67-year-old man with a 10 year history of hiatus hernia associated with an oesophageal stricture presented with dysphagia and coughing after swallowing. Endoscopy revealed a benign oesophageal stricture at 35 cm. Dilatation was performed using a 22 mm Lunderquist-Owman oesophageal dilatation kit (William Cook Europe) balloon under intravenous sedation (6 mg Midazolam Hydrochloride). The balloon was distended three times with ease under fluoroscopic control and no waisting of the balloon was visible on the final dilatation. The patient complained of pain 4 h after the procedure and a chest radiograph was taken revealing no abnormality. The following morning a further chest radiograph revealed extensive consolidation in the left lower lobe.
1060
A water soluble contrast swallow demonstrated a leak from the lower oesophagus. The patient was treated by bed rest and intravenous fluids for 1 week and no surgical intervention was required. The patient was discharged well on the seventh day following the procedure. Case 2 A 59-year-old lady presented with lower oesophageal dysphagia. At endoscopy there was an impassable area of narrowing in the lower oesophagus. Biopsies revealed no evidence of malignancy. After clinical discussion it was decided to perform a balloon dilatation of the stricture to alleviate the symptoms. Endoscopy of the whole lesion was planned for a later date. The dilatation was performed under intravenous sedation (6mg Midazolam Hydrochloride). A balloon catheter was passed easily beyond the lesion under fluoroscopic control. No guide wire was used to negotiate the stricture. A balloon catheter (Lunderquist-Owman oesophageal dilatation kit, William Cook Limited) was inflated twice to its maximum diameter of 22 mm. On the first inflation there was some waisting in the balloon outline but this was not seen at the second inflation. The British Journal of Radiology, November 1991
Case reports
The patient complained of some upper abdominal discomfort and shortness of breath 4 h after the procedure. A chest radiograph was taken with poor inspiration but this revealed no abnormality. After overnight observation, examination revealed some epigastric tenderness but no guarding. The patient was dyspnoeic at rest. A second chest radiograph was taken 23 h after the procedure (Fig. 1) and this revealed a large, left-sided hydropneumothorax. At operation a 4 cm x 2 cm defect was found in the oesophagus and repaired. A water soluble contrast study performed 3 days after surgical repair showed no evidence of a leak and free flow into the stomach. The patient was finally discharged 2 weeks later.
experience chest tightness during inflation but the use of intravenous sedatives and/or analgesics makes it very difficult to quantify this. Evidence of bleeding is commonly seen on the balloon after removal. Grundy and Belli (1988) recommended that a chest radiograph be performed 2-3 h after the procedure and, if normal, that the patient be allowed to eat and drink. La Berge et al (1985) observed their patients for only 1 h. The disturbing feature of our cases was that chest radiographs taken 3-4 h after the procedure showed no abnormality, while those taken after 20 h revealed obvious abnormalities. While it is impractical to keep patients fasting for 24 h routinely, we now only perform this procedure in the morning and post dilatation chest radiographs are taken no less than 6 h after the procedure. If there is any evidence of pleuritic or abdominal symptoms, overnight observation in hospital is advocated, and if symptoms persist we repeat the chest radiograph next morning. If doubt persists a water soluble contrast study can be performed before allowing any fluid or food by mouth. The risk of perforation is probably higher than generally realized and this may be increased when the newly introduced larger balloons of up to 3 cm in diameter are more widely used (William Cook Limited). The post procedural clinical observation of the patient is vital. The chest radiograph is essential but it must only play a part in the patient assessment process. There is pressure to perform this procedure as a day case and this can often be done. The patient's discharge should be supervised by an experienced clinician and facilities to observe the patient overnight should be available if required.
Discussion
References
Rupture of the oesphagus during balloon dilatation is uncommon. The radially directed forces generated are thought to be safer than the longitudinal forces produced during bouginage. Some authors have concluded that the risk of rupture is "virtually eliminated" by this technique (Starck et al, 1984). There is a report of perforation by guide wire (Dawson et al, 1984). Both Gotberg (1982) and La Berge (1985) reported a single case of rupture during balloon dilatation. Maynar et al (1988) reported three ruptures in 170 procedures (2%) involving 35 patients. McLean and LeVeen (1989) demonstrated the reduced shearing forces of balloon compared with bougies in vivo and concluded that balloon dilatation would be expected to have a higher margin of safety. We have experienced two ruptures in a series of 46 procedures in 33 patients. The rupture may not be apparent immediately after the procedure, and in the case reported by La Berge et al (1985) the patient had been discharged home. In our cases the balloons were inflated with ease and the patients did not suffer undue discomfort. Most patients
DAWSON, S. L., MUELLER, P. R., FERRUCCI, J. T., RlCHTER, J. M . , SCHAPIRO, R. H . , BUTCH, R. J. & SlMEONE, J.
Figure 1. Postero-anterior chest radiograph showing a leftsided hydropneumothorax.
Vol. 64, No. 767
F., 1984. Severe esophageal strictures; indications for balloon catheter dilatation. Radiology, 153, 631-635. GOTBERG, S., AFZELIUS, L. E., HAMBRAEUS, G., HEDENBRO, J., LUNDERQUIST, A . , OWMAN, T . & SVENSSON, G., 1982.
Balloon catheter dilatation of strictures in the upper digestive tract. Radiology, 22, 479-483. GRUNDY, A. & BELLI, A., 1988. Balloon dilatation of upper
gastro-intestinal strictures. Clinical Radiology, 39, 229-235. LA BERGE, J. M., KERLAN, R. K., POGANY, A. C. & RING,
E. J., 1985. Esophageal rupture; complication of balloon dilatation. Radiology, 157, 56. MCLEAN, G. K. & LEVEEN, R. F., 1989. Sheer stress in the
performance of esophageal dilatation; comparison of balloon dilatation and bougienage. Radiology, 172, 983-986. MAYNAR, M., GUERRA, C , REYES, R., MAYNOR, J., FACAL, P., CASTANEDA-ZUNIGA, W. R. & LETOURNEAU, J. G., 1988.
Esophageal strictures; balloon dilatation. Radiology, 167, 703-706. STARCK, E., PAOLUCCI, V., HERZER, M. & CRUMMY, A. B.,
1984. Esophageal stenosis; treatment with balloon catheters. Radiology, 153, 637-640.
1061
Case reports BLANC, W. A., BERDON, W. E., BAKER, D. H. & WIGGER, H. J.,
1967. Calcified portal vein thromboemboli in newborn and stillborn infants. Radiology, 88, 287-292. CREMIN, B. J. & Nuss, D., 1974. Calcified hepatoblastoma in a newborn. Journal of Pediatric Surgery, 9, 913-915. FOROUHAR, F., 1982. Meconium peritonitis: pathology, evolution and diagnosis. American Journal of Clinical Pathology, 78, 208-213. FRIEDMAN, A. P., HALLER, J. O., BOYER, B. & COOPER, R.,
1981. Calcified portal vein thromboemboli in infants: radiography and ultrasonography. Radiology, 140, 381-382. LINCE, D. M., PRETORIUS, D. H., MANCO-JOHNSON, M. L., MANCHESTER, D. & CLEWELL, W. H., 1985. The clinical
significance of increased echogenicity in the fetal abdomen. American Journal of Roentgenology, 145, 683-686. Moss, A. A., CLARK, R. E., PALUBINSKAS, A. J. & DELORIMIER,
A. A., 1971. Angiographic appearance of benign and malignant hepatic tumours in infants and children. American Journal of Roentgenology, 113, 61-69. NGUYEN, D. L. & LEONARD, J. C , 1986. Ischaemic hepatic
References ABLOW, R. C. & EFFMAN, E. L., 1972. Hepatic calcification
associated with umbilical vein catheterisation in the newborn infant. American Journal of Roentgenology, 114, 380-385.
necrosis: A cause of fetal liver calcification. American Journal of Roentgenology, 147, 596-597. SHACKELFORD, G. D. & KIRKS, D. R., 1977. Neonatal hepatic
calcification secondary Radiology, 122, 753-757.
to
transplacental
infection.
Oesophageal ruptures complicating balloon dilatation of strictures: a report of two cases By B. M u c c i , M B , ChB, FRCR Department of Diagnostic Radiology, West Cumberland Hospital, Whitehaven, Cumbria CA28 8JG, UK
{Received February 1991 and in revised form April 1991) Keywords: Oesophageal perforation, Balloon dilatation
Balloon dilatation of upper gastro-intestinal tract strictures is accepted as a safe and effective method of dealing with lesions of varying aetiology. Perforation of the oesophagus is a recognized, but rare complication. Two such cases are described and their management is discussed. Case 1 A 67-year-old man with a 10 year history of hiatus hernia associated with an oesophageal stricture presented with dysphagia and coughing after swallowing. Endoscopy revealed a benign oesophageal stricture at 35 cm. Dilatation was performed using a 22 mm Lunderquist-Owman oesophageal dilatation kit (William Cook Europe) balloon under intravenous sedation (6 mg Midazolam Hydrochloride). The balloon was distended three times with ease under fluoroscopic control and no waisting of the balloon was visible on the final dilatation. The patient complained of pain 4 h after the procedure and a chest radiograph was taken revealing no abnormality. The following morning a further chest radiograph revealed extensive consolidation in the left lower lobe.
1060
A water soluble contrast swallow demonstrated a leak from the lower oesophagus. The patient was treated by bed rest and intravenous fluids for 1 week and no surgical intervention was required. The patient was discharged well on the seventh day following the procedure. Case 2 A 59-year-old lady presented with lower oesophageal dysphagia. At endoscopy there was an impassable area of narrowing in the lower oesophagus. Biopsies revealed no evidence of malignancy. After clinical discussion it was decided to perform a balloon dilatation of the stricture to alleviate the symptoms. Endoscopy of the whole lesion was planned for a later date. The dilatation was performed under intravenous sedation (6mg Midazolam Hydrochloride). A balloon catheter was passed easily beyond the lesion under fluoroscopic control. No guide wire was used to negotiate the stricture. A balloon catheter (Lunderquist-Owman oesophageal dilatation kit, William Cook Limited) was inflated twice to its maximum diameter of 22 mm. On the first inflation there was some waisting in the balloon outline but this was not seen at the second inflation. The British Journal of Radiology, November 1991
Case reports
The patient complained of some upper abdominal discomfort and shortness of breath 4 h after the procedure. A chest radiograph was taken with poor inspiration but this revealed no abnormality. After overnight observation, examination revealed some epigastric tenderness but no guarding. The patient was dyspnoeic at rest. A second chest radiograph was taken 23 h after the procedure (Fig. 1) and this revealed a large, left-sided hydropneumothorax. At operation a 4 cm x 2 cm defect was found in the oesophagus and repaired. A water soluble contrast study performed 3 days after surgical repair showed no evidence of a leak and free flow into the stomach. The patient was finally discharged 2 weeks later.
experience chest tightness during inflation but the use of intravenous sedatives and/or analgesics makes it very difficult to quantify this. Evidence of bleeding is commonly seen on the balloon after removal. Grundy and Belli (1988) recommended that a chest radiograph be performed 2-3 h after the procedure and, if normal, that the patient be allowed to eat and drink. La Berge et al (1985) observed their patients for only 1 h. The disturbing feature of our cases was that chest radiographs taken 3-4 h after the procedure showed no abnormality, while those taken after 20 h revealed obvious abnormalities. While it is impractical to keep patients fasting for 24 h routinely, we now only perform this procedure in the morning and post dilatation chest radiographs are taken no less than 6 h after the procedure. If there is any evidence of pleuritic or abdominal symptoms, overnight observation in hospital is advocated, and if symptoms persist we repeat the chest radiograph next morning. If doubt persists a water soluble contrast study can be performed before allowing any fluid or food by mouth. The risk of perforation is probably higher than generally realized and this may be increased when the newly introduced larger balloons of up to 3 cm in diameter are more widely used (William Cook Limited). The post procedural clinical observation of the patient is vital. The chest radiograph is essential but it must only play a part in the patient assessment process. There is pressure to perform this procedure as a day case and this can often be done. The patient's discharge should be supervised by an experienced clinician and facilities to observe the patient overnight should be available if required.
Discussion
References
Rupture of the oesphagus during balloon dilatation is uncommon. The radially directed forces generated are thought to be safer than the longitudinal forces produced during bouginage. Some authors have concluded that the risk of rupture is "virtually eliminated" by this technique (Starck et al, 1984). There is a report of perforation by guide wire (Dawson et al, 1984). Both Gotberg (1982) and La Berge (1985) reported a single case of rupture during balloon dilatation. Maynar et al (1988) reported three ruptures in 170 procedures (2%) involving 35 patients. McLean and LeVeen (1989) demonstrated the reduced shearing forces of balloon compared with bougies in vivo and concluded that balloon dilatation would be expected to have a higher margin of safety. We have experienced two ruptures in a series of 46 procedures in 33 patients. The rupture may not be apparent immediately after the procedure, and in the case reported by La Berge et al (1985) the patient had been discharged home. In our cases the balloons were inflated with ease and the patients did not suffer undue discomfort. Most patients
DAWSON, S. L., MUELLER, P. R., FERRUCCI, J. T., RlCHTER, J. M . , SCHAPIRO, R. H . , BUTCH, R. J. & SlMEONE, J.
Figure 1. Postero-anterior chest radiograph showing a leftsided hydropneumothorax.
Vol. 64, No. 767
F., 1984. Severe esophageal strictures; indications for balloon catheter dilatation. Radiology, 153, 631-635. GOTBERG, S., AFZELIUS, L. E., HAMBRAEUS, G., HEDENBRO, J., LUNDERQUIST, A . , OWMAN, T . & SVENSSON, G., 1982.
Balloon catheter dilatation of strictures in the upper digestive tract. Radiology, 22, 479-483. GRUNDY, A. & BELLI, A., 1988. Balloon dilatation of upper
gastro-intestinal strictures. Clinical Radiology, 39, 229-235. LA BERGE, J. M., KERLAN, R. K., POGANY, A. C. & RING,
E. J., 1985. Esophageal rupture; complication of balloon dilatation. Radiology, 157, 56. MCLEAN, G. K. & LEVEEN, R. F., 1989. Sheer stress in the
performance of esophageal dilatation; comparison of balloon dilatation and bougienage. Radiology, 172, 983-986. MAYNAR, M., GUERRA, C , REYES, R., MAYNOR, J., FACAL, P., CASTANEDA-ZUNIGA, W. R. & LETOURNEAU, J. G., 1988.
Esophageal strictures; balloon dilatation. Radiology, 167, 703-706. STARCK, E., PAOLUCCI, V., HERZER, M. & CRUMMY, A. B.,
1984. Esophageal stenosis; treatment with balloon catheters. Radiology, 153, 637-640.
1061
