Value of MDCT in Diagnosis and Management of Esophageal Sharp or Pointed Foreign Bodies According to Level of Esophagus AJR 201, November 2013 W707 image quality; therefore, it could be beneficial for.
Gastrointestinal Imaging • Original Research Ma et al MDCT for Esophageal Foreign Body Downloaded from www.ajronline.org by 116.110.42.190 on 08/15/22 from IP address 116.110.42.190 Copyright ARRS For personal use only; all rights reserved Gastrointestinal Imaging Original Research Value of MDCT in Diagnosis and Management of Esophageal Sharp or Pointed Foreign Bodies According to Level of Esophagus Jeehyun Ma1 Doo Kyoung Kang Jae-Ik Bae Kyung Joo Park Joo Sung Sun Ma J, Kang DK, Bae JI, Park KJ, Sun JS OBJECTIVE The purpose of this study was to validate the usefulness of MDCT for diagnosis of a sharp or pointed esophageal foreign body according to esophageal level MATERIALS AND METHODS Forty-two patients with a history of sharp or pointed foreign body ingestion were reviewed retrospectively Two observers interpreted the CT and the conventional radiography datasets separately If a foreign body was directly identified, it was regarded as a positive finding Even if no high-density foreign body was found, detection of a secondary finding was considered to be a positive finding Diagnostic performance of MDCT and conventional radiography were compared according to esophageal level Final diagnosis was made by esophagoscopy or surgery in addition to the clinicoradiologic result RESULTS MDCT was statistically superior to conventional radiography for diagnosis of a thoracic esophageal foreign body for both observers (p < 0.001 for each) No significant difference in sensitivity between CT and conventional radiography for diagnosis of cervical esophageal foreign body was noted regardless of observer Both observers could identify all complicated conditions with MDCT regardless of esophageal level However, in two of three cases of complicated thoracic esophageal foreign bodies, neither observer could detect foreign bodies on conventional radiography; furthermore, the observers could not identify pneumomediastinum CONCLUSION In cases of sharp or pointed foreign body ingestion, if the result of an initial inspection of oro- and hypopharynx reveals negative findings, the first imaging modality should be MDCT for better diagnosis and management E Keywords: conventional radiography, esophageal foreign body, esophagus, MDCT, sharp or pointed foreign body DOI:10.2214/AJR.12.8517 Received December 29, 2011; accepted after revision January 1, 2013 All authors: Department of Radiology, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtonggu, Suwon 443-721, Korea Address correspondence to J S Sun (sunnahn@ajou.ac.kr) WEB This is a web exclusive article AJR 2013; 201:W707–W711 0361–803X/13/2015–W707 © American Roentgen Ray Society sophageal foreign bodies are a frequently encountered problem in daily practice In particular, when sharp or pointed foreign bodies (e.g., metallic objects, animal or fish bones, and toothpicks) are ingested, the risk of perforation is higher than with blunt foreign bodies [1] Therefore, if not appropriately and timely managed, ingestion of a sharp foreign body can cause serious conditions, such as esophageal perforation with resultant fatal mediastinitis [2] Although radiologic evaluation is helpful in avoiding morbidity from unnecessary endoscopy, conventional radiography has been shown to have poor diagnostic performance in several studies [3, 4] and a barium swallow study is not commonly performed because of several disadvantages [5] Recently, the usefulness of CT in esophageal foreign body diagnosis has been shown [3, 6–9], but only a few reports regarding MDCT have been published [10, 11] MDCT has the capability for rapid scanning and good image quality; therefore, it could be beneficial for emergency radiology Many investigations have focused on imaging studies for impacted foreign bodies in the cervical esophagus [6, 12–15]; however, in our experience, an esophageal foreign body is difficult to identify with radiography when it is stuck in the thoracic esophagus The location of the foreign body has been suggested as an important factor affecting its detection [3] Therefore, we sought to validate the usefulness of MDCT for sharp or pointed esophageal foreign body diagnosis according to esophageal level Materials and Methods Patient Population The institutional review board of our hospital approved this retrospective study, and patient consent was waived During a period of 31 months from January 2007 to July 2009, a total of 87 patients with histories of foreign body ingestion who visited the emergency department of a tertiary referral university hospital were eligible to be included, and ulti- AJR:201, November 2013 W707 Ma et al 87 patients were eligible Downloaded from www.ajronline.org by 116.110.42.190 on 08/15/22 from IP address 116.110.42.190 Copyright ARRS For personal use only; all rights reserved 21 were excluded due to blunt foreign body Fig 1—Chart shows inclusions and exclusions of study patients perforation were regarded as complicated The radiologists also recorded the level of the esophagus at which the foreign body was lodged The level of the esophagus was classified into cervical and thoracic esophagus by the thoracic inlet level 66 with sharp or pointed foreign body CT Examination 24 were excluded: direct retrieval of foreign body 42 were included in the analysis mately 42 patients (18 women and 24 men; mean age, 47 years) were included in this study (Fig 1) Inclusion criteria for analysis included patients with obvious history and symptoms of sharp or pointed foreign body ingestion; indirect laryngoscopy with a negative result; neck and chest radiography; and, when indicated, abdominal radiography and chest MDCT Exclusion criteria were an obvious history of blunt foreign body ingestion and a sharp or pointed foreign body stuck in the oropharynx that could be retrieved directly Image Interpretation Datasets of chest MDCT and radiography of patients were anonymized and randomly reorga- nized in the PACS system Then, a chest radiologist with years of experience in clinical chest CT and a fourth-year resident independently interpreted conventional radiography and chest CT in different reading sessions The two observers were aware of foreign body ingestion but were blinded to the results If a high-density foreign body was identified on conventional radiographs and CT images, it was regarded as a positive finding Even if a highdensity foreign body was not found, detection of a secondary finding, such as soft-tissue swelling, focal edema, hematoma, or abnormal gas accumulation, was also considered to be a positive finding Cases with pneumomediastinum or esophageal A C W708 All chest MDCT examinations were performed using a 16-MDCT scanner (Sensation 16, Siemens Healthcare) Thirty-four patients underwent unenhanced CT only Eight patients who underwent unenhanced and contrast-enhanced CT were given 100 mL of nonionic contrast material (iopamidol, Iopamiro 300, Bracco; or iopromide, Ultravist 300, Bayer Schering Pharma) injected IV with a mechanical automated injector with a fixed delay time of 45 seconds The scanning parameters were as follows: collimation, 16 × 1.5 mm; tube rotation time, 0.5 second; pitch, 1.5; 200 effective mAs; 120 kV Image data were reconstructed at a slice thickness setting of mm with 3-mm reconstruction increments Conventional Radiography Examinations All chest and neck anteroposterior and lateral radiographs were obtained in the erect position and B D Fig 2—59-year-old man complaining of accidental ingestion of fish bone 48 hours previously After two failures of esophagoscopic removal attempts in this patient, open thoracotomy was performed without complication A, No identifiable foreign body or secondary finding of esophageal foreign body was observed on radiograph B, Axial CT image shows well-defined linear hyperdensity (arrowhead) in thoracic esophagus at level of aortic arch Pneumomediastinum is well depicted (arrow) C, Coronal reconstruction image shows V-shaped fish bone with papillae lodged in mid thoracic esophagus (arrowhead) Pneumomediastinum is also well identified (arrow) D, Photograph shows foreign body removed from patient’s esophagus by open thoracotomy AJR:201, November 2013 MDCT for Esophageal Foreign Body TABLE 1: Diagnostic Performance and Intermodality Comparison of MDCT and Conventional Radiography Observer (%) Imaging Modality MDCT Observer (%) Radiography p MDCT Radiography p < 0.001 97.4 (37/38) [92.3–100] 47.4 (18/38) [31.5–63.2] < 0.001 97.6 (41/42) [93–100] 52.4 (22/42) [37.3–67.5] 94.7 (18/19) [84.7–100] 84.2 (16/19) [67.8–100] 94.7 (18/19) [84.7–100] 84.2 (16/19) [67.8–100] 100 (19/19) [100–100] 10.5 (2/19) [0–24.3] 100 (19/19) [100–100] 10.5 (2/19) [0–24.3] Downloaded from www.ajronline.org by 116.110.42.190 on 08/15/22 from IP address 116.110.42.190 Copyright ARRS For personal use only; all rights reserved Overall (n = 42) Sensitivity 94.7 (36/38) [87.6–100] 42.1 (16/38) [26.4–57.8] Accuracy 95.2 (40/42) [88.8–100] 47.6 (20/42) [32.5–62.7] Sensitivity 100 (19/19) [100–100] 73.7 (14/19) [53.9–93.5] Accuracy 100 (19/19) [100–100] 73.7 (14/19) [53.9–93.5] Cervical (n = 19) 0.06 0.59 Thoracic (n = 19) Sensitivity 89.5 (17/19) [75.7–100] 10.5 (2/19) [0–24.3] Accuracy 89.5 (17/19) [75.7–100] 10.5 (2/19) [0–24.3] < 0.001 < 0.001 Note—Data in parentheses are number/total, and data in brackets are 95% CI Proportion test was used for p value abdominal radiographs were obtained in the supine position All radiographs were obtained with a computed radiography machine (UD150 L-30E, Shimadzu) with 120 kVp at 1–2 mAs (chest posteroanterior), 65–75 kVp at 8–12 mAs (neck anteroposterior and lateral), and 75–85 kVp at 20–30 mAs (abdomen supine) The digital imaging device was an FCR5000 plus (Fujifilm Medical Systems) Reference Standard Final diagnosis of an esophageal foreign body was made by detection of the foreign body at esophagoscopy or surgery in addition to the clinicoradiologic result In cases of nonidentification of foreign body on physical and radiologic evaluation with a symptomatic patient, flexible esophagoscopy was also performed If a foreign body was not found with flexible esophagoscopy and the patient was asymptomatic for 2–3 days of observation, we confirmed a negative diagnosis Statistical Analysis Sensitivity and accuracy for the use of MDCT and radiography were calculated regarding the ability of each modality to depict an esophageal foreign body according to the level of the esophagus The interobserver and intermodality comparisons of sensitivity were performed according to the level of the esophagus by a proportion test using R, version 2.14.1 (R Foundation for Statistical Computing, R Core Team) Kappa statistics were used to calculate interreader agreement using MedCalc for Windows, version 8.2.1.0 (MedCalc Software) Every calculated p value was two-sided, and a value less than 0.05 was considered statistically significant Results Thirty-eight patients (90.5%, 38/42) had sharp or pointed esophageal foreign bodies, and the remaining four patients (9.5%, 4/42) were diagnosed as not having esophageal foreign bodies Negative results were observed with both radiologic evaluation and flexible esophagoscopy in addition to clinical follow-up Most cases of esophageal foreign bodies were fish bones (31 of 38 cases, 81.6%) The other types of foreign bodies were chicken bones (five cases) and metallic foreign bodies (two cases) The level at which the foreign body was lodged was the cervical esophagus in 50% (19/38) of cases and in the thoracic esophagus in 50% (19/38) The mean duration of impaction was hours (range, 1–52 hours) Among 38 patients who were diagnosed as having esophageal sharp or pointed foreign bodies, a total of 31 patients (81.6%, 31/38) showed an uncomplicated esophageal foreign body, and seven patients (18.4%, 7/38) were diagnosed as complicated cases (i.e., pneumomediastinum or esophageal perforation) on CT examinations The 31 patients with uncomplicated esophageal foreign sharp or pointed bodies were treated with flexible esophagoscopy without general anesthesia, and iatrogenic esophageal perforation with resultant mediastinitis occurred in only one case (3.1%, 1/32) that was successfully treated conservatively In the cases of seven patients with complicated esophageal foreign bodies, the sharp or pointed foreign bodies of five patients were removed by rigid esophagoscopy under general anesthesia followed by conservative management Two patients (2/38) were treated by surgery (cervical esophagotomy and thoracotomy) due to prior endoscopic removal failures (Fig 2) No major complications were noted in patients who were treated surgically Sensitivity and accuracy of MDCT and radiography were calculated regarding the ability of each modality to detect foreign bodies directly or to detect secondary findings (Table 1) The overall sensitivity for the correct identification and localization of esophageal foreign bodies was significantly higher overall for both readers with MDCT (94–97% vs 42–47%, respectively, p < 0.001) The sensitivity and accuracy of chest MDCT were also significantly better than radiography for diagnosis of a thoracic esophageal foreign body for both observers (89.5–100% vs 10.5%, p < 0.001 for both comparisons) In contradistinction, there was a trend for improved accurate detection of cervical foreign bodies by reader (100% vs 74%, p = 0.06), but there was no such trend for the second reader (accuracy 94.7% vs 84.2%, p = 0.59) The kappa statistic showed substantial agreement between the two observers for MDCT (0.69 [95% CI, 0.36–1.0]) and conventional radiography (0.80 [0.62–0.99]), and there was no interobserver difference of sensitivity according to the level of esophagus (p > 0.05 regardless of esophageal level) Table summarizes reader detection of the seven cases of complicated esophageal foreign bodies In these cases, both readers missed two of three esophageal perforations in the thoracic esophagus on radiography but not on MDCT Discussion Sharp or pointed foreign bodies stuck in the esophagus represent a medical emergency because the risk of complications caused by such objects is as high as 35% [16] They are often more challenging to remove than blunt foreign bodies Unlike blunt foreign bodies, such as coins, a sharp or pointed object that has reached the stomach or proximal duodenum should still be retrieved endoscopically if possible [17] Therefore, a patient who complains of sharp or pointed foreign body ingestion should be evaluated carefully to identify the exact anatomic location and size of the foreign body before AJR:201, November 2013 W709 Downloaded from www.ajronline.org by 116.110.42.190 on 08/15/22 from IP address 116.110.42.190 Copyright ARRS For personal use only; all rights reserved Ma et al Fig 3—54-year-old man complaining of accidental ingestion of fish bone hours before as well as persistence of cervical pain and odynophagia A and B, Conventional radiographs of chest (A) and head (B) show free air (arrows) in mediastinum and neck, representing pneumomediastinum without evidence of direct visualization of foreign body C, Axial CT image shows well-defined linear hyperdensity (arrowhead) in proximal thoracic esophagus Pneumomediastinum is also well depicted (arrows) D, Photograph shows foreign body removed from patient’s esophagus by rigid esophagoscopy under general anesthesia A B C extraction using endoscopy to avoid additional trauma to the surrounding tissue or unnecessary endoscopy Generally, foreign bodies stuck in the tonsils and upper oropharynx can be removed directly under a headlight with or without an indirect laryngeal mirror However, removal of a foreign body deeply stuck in a lower level of the oropharynx is sometimes technically difficult under indirect mirror guidance [18, 19], and foreign bodies in the hypopharynx and esophagus almost always need radiologic evaluation to show the presence of the foreign body and its location Radiologic evaluation is also needed to identify the presence of complications, such as pneumomediastinum, before endoscopic therapy Radiography of the neck and chest are the most commonly and easily used methods for diagnosis of esophageal foreign bodies Although visibility of a fish bone by radiography may depend on the species of fish [20], radiography has generally been considered to be insufficient for detection of esophageal foreign bodies [3, 6–9, 21] However, in this study, although the sensitivity of MDCT was higher W710 than that of radiography for cervical esophageal foreign bodies, no significant intermodality difference was revealed (Table 1) We speculate that there could be two possible reasons: Almost all foreign bodies in this study were fish bones (81.6%), and differences in visibility on radiography could depend on the species of fish [20] Unfortunately the medical records could not identify the species of fish ingested, but fish bones perhaps would be more easily detected in cervical radiography than a nonradiodense sharp object, such as a toothpick This result could also be due to the relatively small number of cases in this study Further study with a well-controlled large population would be necessary to validate the findings Some endoscopists have recommended that the patient be managed only by endoscopy after an unrevealing radiographic study because swallowed barium may delay the diagnosis and impede subsequent esophagoscopy [5] Furthermore, esophagoscopy is directly performed without an imaging assessment in some hospitals, although the procedure, even D with flexible endoscopes, is an invasive technique with a potential morbidity risk [8] CT has been spotlighted as a useful diagnostic tool with high sensitivity for esophageal foreign body diagnosis in several reports [3, 6–9, 21] CT is capable of greater contrast and spatial resolution Therefore, slightly calcified objects not seen on conventional radiography can be found on CT Using MDCT in the emergency department facilitated shortening of the study time and added diagnostic accuracy CT can also clearly visualize the damage or secondary inflammatory changes in the adjacent structures Moreover, CT can provide important additional information for the diagnosis of fatal complications, such as mediastinitis, or carotid- or aortic-esophageal fistula, and it can provide a higher chance for successful management of these severe cases In the current study, MDCT showed significantly greater sensitivity than radiography for diagnosis of thoracic esophageal foreign bodies in intermodality comparison (Table 1) In cases of thoracic esophageal foreign body presence, only two cases (10.5%, 2/19) AJR:201, November 2013 MDCT for Esophageal Foreign Body TABLE 2: Detection of Seven Complicated Esophageal Foreign Bodies According to Esophageal Level Observer Downloaded from www.ajronline.org by 116.110.42.190 on 08/15/22 from IP address 116.110.42.190 Copyright ARRS For personal use only; all rights reserved Level Observer Detected Missed Detected Missed MDCT (100) (100) Radiography (75) (25) (100) Cervical (n = 4) Thoracic (n = MDCT (100) (100) Radiography (33.3) (66.7) (33.3) (66.7) Note—Data in parentheses are percentages were recorded as positive findings for both observers using conventional radiography One case was identified by a secondary finding of pneumomediastinum (Fig 3), and the other was a metallic foreign body that consisted of heavily radiopaque material There were seven cases of complicated esophageal foreign bodies (four cervical and three thoracic), and both observers could identify all complicated conditions with MDCT regardless of esophageal level (Table 2) However, using conventional radiography, neither observer could detect foreign bodies in the complicated cases Furthermore, they could not identify pneumomediastinum in two of three cases of complicated thoracic esophageal foreign bodies In four cases of complicated cervical esophageal foreign bodies, observer missed the positive finding of a complicated case These results could support the conclusion that the usefulness of MDCT for diagnosis of an esophageal foreign body would be different depending on the location Although the sensitivity of radiography for cervical esophageal foreign bodies seems to be comparable with that of MDCT, the ability to show complications should be validated Some limitations exist in the current study First, the study has the inherent flaws of a retrospective study, such as the use of contrastenhanced CT at the physician’s request Second, the number of cases was relatively small; therefore, further studies with a large patient population and well-controlled conditions are needed Third, there was no case of nonradiodense foreign body in this study, and almost all the foreign bodies were fish bones In conclusion, MDCT is superior to radiography for the detection of thoracic esophageal foreign bodies and provides additional crucial information in complicated cases Therefore, after an initial negative clinical inspection of the oro- and hypopharynx for suspected sharp or pointed esophageal foreign bodies, MDCT should be first choice modality of diagnostic approach in emergency circumstances Acknowledgments We thank Anjali Basnyat Bista for preparation of the manuscript in English and Hyun Young Lee from the Department of Biostatistics for statistical assistance References Selivanov V, Sheldon GF, Cello JP, Crass RA Management of foreign body ingestion Ann Surg 1984; 199:187–191 Ginsberg GG Management of ingested foreign objects and food bolus impactions Gastrointest Endosc 1995; 41:33–38 Lue AJ, Fang WD, Manolidis S Use of plain radiography and computed tomography to identify fish bone foreign bodies Otolaryngol Head Neck Surg 2000; 123:435–438 Sundgren PC, Burnett A, Maly PV Value of radiography in the management of possible fishbone ingestion Ann Otol Rhinol 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Emerg Med J 2007; 24:48–49 16 Eisen GM, Baron TH, Dominitz JA, et al Guideline for the management of ingested foreign bodies Gastrointest Endosc 2002; 55:802–806 17 Smith MT, Wong RK Esophageal foreign bodies: types and techniques for removal Curr Treat Options Gastroenterol 2006; 9:75–84 18 O’Flynn P, Simo R Fish bones and other foreign bodies Clin Otolaryngol Allied Sci 1993; 18:231–233 19 Jones NS, Lannigan FJ, Salama NY Foreign bodies in the throat: a prospective study of 388 cases J Laryngol Otol 1991; 105:104–108 20 Ell SR, Sprigg A, Parker AJ A multi-observer study examining the radiographic visibility of fishbone foreign bodies J R Soc Med 1996; 89:31–34 21 Eliashar R, Dano I, Dangoor E, Braverman I, Sichel JY Computed tomography diagnosis of esophageal bone impaction: a prospective study Ann Otol Rhinol Laryngol 1999; 108:708–710 AJR:201, November 2013 W711 ... ability of each modality to depict an esophageal foreign body according to the level of the esophagus The interobserver and intermodality comparisons of sensitivity were performed according to the level. .. classified into cervical and thoracic esophagus by the thoracic inlet level 66 with sharp or pointed foreign body CT Examination 24 were excluded: direct retrieval of foreign body 42 were included in. .. women and 24 men; mean age, 47 years) were included in this study (Fig 1) Inclusion criteria for analysis included patients with obvious history and symptoms of sharp or pointed foreign body ingestion;