Korean J Radiol.  2014 Feb;15(1):173-177. 10.3348/kjr.2014.15.1.173.

Spontaneous Intramural Full-Length Dissection of Esophagus Treated with Surgical Intervention: Multidetector CT Diagnosis with Multiplanar Reformations and Virtual Endoscopic Display

• Khil EK
• Lee H
• Her K

• KMID: 1711495
• DOI: http://doi.org/10.3348/kjr.2014.15.1.173

Abstract

Intramural esophageal dissection (IED) is an uncommon disorder characterized by separation of the mucosal and submucosal layers of the esophagus. Iatrogenic intervention is the most common cause of IED, but spontaneous dissection is rare. We report an unusually complicated case of spontaneous IED that involved the full-length of the esophagus that necessitated surgical intervention due to infection of the false lumen. In this case, chest computed tomography successfully established the diagnosis and aided in pre-operative evaluation with the use of various image post-processing techniques.

Keyword

Esophagus; Intramural dissection; Abscess; Computed tomography; Post-processing techniques

MeSH Terms

Esophageal Diseases/*radiography/*surgery
Esophagoscopy/methods
Esophagus/injuries/radiography
Humans
Male
Middle Aged
*Multidetector Computed Tomography
Rare Diseases/*radiography/*surgery
Rupture, Spontaneous/radiography/surgery

Figure

• 

  Fig. 1 54-year-old man with spontaneous intramural dissection of esophagus. A. Endoscopy performed at another hospital just prior to admission to our hospital demonstrated laceration (white arrow) in mid-thoracic esophageal mucosa. B, C. Axial (B) and coronal and sagittal images (C) from enhanced CT showed esophageal double lumen, intervening mucosal flap, and absence of mediastinal free air. Air-fluid level and mottled soft tissue densities (white arrowhead) are seen in false lumen (F), consistent with infected fluid and food materials. D. Curved MPR images show two mucosal tears on dissection flap at cervical and mid-thoracic esophagus, and full extent of false lumen in single image plane. Note tears at cervical (open arrowheads) and mid-thoracic (white arrows) esophagus. AA = aortic arch, F = false lumen, T = true lumen. E. Three-dimensional volume rendering images demonstrated mucosal tear (white arrow) in dissection flap between false and true lumens. Note level of tracheal bifurcation (open arrow). Images run from proximal (left, upper) to distal (right, lower) esophagus. F. Virtual CT endoscopic views reconstructed from original CT dataset also depicted endoluminal images of air-distended false lumen, as well as mucosal lacerations on dissection flap (white arrow). False lumen extended from cervical to distal esophagus. Images run from proximal (left, upper) to distal (right, lower) esophagus. F = false lumen, T = true lumen, L = left, R = right, A = anterior, P = posterior. G. Gross surgical specimen of resected esophagus and part of gastric fundus (left end). Resected esophagus was opened longitudinally and stretched. Note thin and whitish esophageal mucosa (white arrows) separated from dark submucosal and muscle layers.

Reference

1. Krishnama MS, Ramadan MF, Curtisa J. Intramural esophageal dissection: CT imaging features. Eur J Radiol (extra). 2005; 56:17–19.

2. Chiu HH, Lee SY. Intramural dissection of the esophagus endoscopic findings. J Intern Med Taiwan. 2006; 17:302–305.

3. Marks IN, Keet AD. Intramural rupture of the oesophagus. Br Med J. 1968; 3:536–537.

4. Kim SH, Lee SO. Circumferential intramural esophageal dissection successfully treated by endoscopic procedure and metal stent insertion. J Gastroenterol. 2005; 40:1065–1069.

5. Soulellis CA, Hilzenrat N, Levental M. Intramucosal esophageal dissection leading to esophageal perforation: case report and review of the literature. Gastroenterol Hepatol (N Y). 2008; 4:362–365.

6. Young CA, Menias CO, Bhalla S, Prasad SR. CT features of esophageal emergencies. Radiographics. 2008; 28:1541–1553.

7. Hsu CC, Changchien CS. Endoscopic and radiological features of intramural esophageal dissection. Endoscopy. 2001; 33:379–381.

8. Wu HC, Hsia JY, Hsu CP. Esophageal laceration with intramural dissection mimics esophageal perforation. Interact Cardiovasc Thorac Surg. 2008; 7:864–865.

9. Kim SH, Lee JM, Han JK, Kim YH, Lee JY, Lee HJ, et al. Three-dimensional MDCT imaging and CT esophagography for evaluation of esophageal tumors: preliminary study. Eur Radiol. 2006; 16:2418–2426.

10. Fadoo F, Ruiz DE, Dawn SK, Webb WR, Gotway MB. Helical CT esophagography for the evaluation of suspected esophageal perforation or rupture. AJR Am J Roentgenol. 2004; 182:1177–1179.