Medical Image of the Week: Mediastinal Metastases Causing Right Ventricular Outflow Obstruction

Figure 1. Computed tomography (CT) of chest showed large right mediastinal mass (arrow) causing mass effect on the heart.

Figure 2.  Echocardiography showing large extra-cardiac mass (white arrow) compressing on right ventricle and its outflow tract (black arrow).

A 36-year-old man with a history of testicular choriocarcinoma with metastases to the lung presented with a 2-days history of hemoptysis. Initial diagnosis of the malignancy was made about 5 months earlier and he was treated with platinum based chemotherapy with a partial response.

He reported two days of significant hemoptysis, associated with shortness of breath and pleuritic chest pain and rapidly developed acute hypoxic respiratory failure requiring emergent intubation and mechanical ventilation. Computed tomography (CT) of chest showed large right mediastinal mass with diffuse reticular and nodular opacities predominantly in the left lung (Figure 1).

A pulmonary angiogram was performed that showed multiple active bleeding sites in the bronchial arterial system. These were treated with embolization. He developed shock and during investigations the echocardiogram showed a significant compression of the superior vena cava, right atrium and right ventricle by the malignant mass (Figure 2). Despite aggressive therapy and resuscitative therapies he continued to deteriorate and did not survive the hospital stay.

Mediastinal tumors are a rare cause of extrinsic right ventricular outflow tract (RVOT) obstruction. Echocardiography is an important tool in the assessment of hemodynamic effects caused due to such pathology including degree of compression and pressure gradients.

Kai Rou Tey MD¹, Bhupinder Natt MD²

¹Department of Internal Medicine, University of Arizona College of Medicine- South Campus, Tucson, AZ USA

²Division of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona Medical Center, Tucson, AZ USA

Cite as: Tey KR, Natt B. Medical image of the week: mediastinal metastases causing right ventricular outflow obstruction. Southwest J Pulm Crit Care. 2016:12(1):22-3. doi: http://dx.doi.org/10.13175/swjpcc145-15 PDF

Medical Image of the Week: Phytobezoar

Figure 1. Supine portable abdominal radiograph. Note the massively distended stomach, outlined by the arrows, with an internal mottled appearance. There is inferior displacement of the transverse colon (arrowhead) contouring to the greater curvature of the stomach.

A 10-year-old boy with a history of non-verbal autism presented to the hospital with symptoms of chronic malnourishment. He was recently started on a specific carbohydrate rich diet, as outlined by a popular mainstream nutrition book, with hopes of improvement in adverse behavior. Prior to the start of this new diet, he consistently demonstrated an increased craving for food and was described to have an insatiable appetite. Though he was relatively non-verbal at baseline, he intermittently voiced his hunger and associated abdominal pain.

A supine abdominal radiograph obtained immediately after admission showed a moderate gastric distension with a significant stool burden. Follow-up radiographs of the abdomen were obtained after two days of medical attempts to clear out the gastrointestinal system. The supine frontal radiograph at this time showed a massively distended stomach with a mottled appearance and considerable mass effect on the transverse colon (Figure 1). The interpreting pediatric radiologist immediately raised a diagnosis of gastric bezoar, which was later confirmed intra-operatively. Initially, an endoscopic approach was tried in an attempt to evacuate the stomach. However, considering the tremendous compaction of the phytobezoar, laparotomy was performed. After confirmation of normal gastric anatomy, several liters of vegetable material were removed from the stomach, and the gastrotomy was closed.

Gastric bezoar is defined as a gastric foreign body resulting from accumulation of ingested material, often found as a hard mass or concretions within the stomach (1). Bezoars are classified according to the contents; phytobezoars contain vegetable materials, whereas trichobezoars contains hair (2). Bezoars usually form in the stomach and can pass into the small bowel where they occasionally cause obstruction. Characteristic radiographic findings can point to the diagnosis of bezoar on plain film radiographs while barium studies are often confirmatory. Many interventions have been described for the treatment of phytobezoars from carbonated nasogastric lavages to endoscopic retrieval (3).  However, in severe cases, a surgical approach is necessary in order to prevent further complications.

Amrit Hansra, MD and Unni Udayasankar, MD

Department of Medical Imaging

University of Arizona

Tucson, AZ USA

References

1. Kadian RS, Rose JF, Mann NS. Gastric bezoars--spontaneous resolution. Am J Gastroenterol. 1978;70:79-82. [PubMed]
2. Lee J. Bezoars and foreign bodies of the stomach. Gastrointest Endosc Clin N Am. 1996;6:605-19. [PubMed]
3. Song KY, Choi BJ, Kim SN, Park CH. Laparoscopic removal of gastric bezoar. Surg Laparosc Endosc Percutan Tech. 2007;17:42-4. [CrossRef] [PubMed]

Cite as: Hansra A, Udayasankar U. Medical image of the week: phytobezoar. Southwest J Pulm Crit Care. 2016;12(1):20-1. doi: http://dx.doi.org/10.13175/swjpcc142-15 PDF