Medical Image of the Week: Mediastinal Lipomatosis

Figure 1. Chest X-ray showing right sided mediastinal mass.

Figure 2. Coronal (A) and axial (B) CT Images showing a right paratracheal homogenously fat-enhancing mass.

A 61-year-old man presented to the pulmonary clinic for evaluation of a chronic cough of 6 months’ duration.  Other medical problems included class three obesity, obstructive sleep apnea on CPAP therapy, and hypertension.  Chest X-Ray (Figure 1) revealed a right mediastinal mass which then prompted a chest CT to be performed. The chest CT (Figure 2) demonstrated a homogenously enhancing, well circumscribed and fat-attenuating 8 x 5 cm mass in the right paratracheal region without invasion or compression into surrounding structures.

Mediastinal lipomatosis was diagnosed.  This is a benign soft tissue tumor made of mature adipocytes that can be seen with obesity, chronic corticosteroid use, and Cushing’s syndrome.  They are thought to represent up to 2.3% of all primary mediastinal tumors (1).  They are occasionally associated with compression of surrounding structures which can cause superior vena cava syndrome, dry cough, dysphagia, and occasionally arrhythmias (2).  Management is typically conservative with weight loss encouraged unless mass effect is present that significantly affects quality of life, in which case surgical options may be explored. 

Although this patient’s cough could be due to this lipoma, he also had symptoms of cough possibly exacerbated by severe gastroesophageal reflux disease which was not yet managed.  A trial of a proton pump inhibitor was pursued with follow-up arranged to determine if further intervention is necessary.

Bryan Borg MD and James Knepler MD

Department of Medicine

Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

University of Arizona

Tucson, AZ USA

References

1. Gaerte SC, Meyer CA, Winer-Muram HT. Fat-containing lesions of the chest. Radiographics. 2002;22:61-78. [CrossRef] [PubMed]
2. Cutilli T, Schietroma M, Marcelli VA, Ascani G, Corbacelli A. Giant cervico-mediastinal lipoma. A clinical case. Minerva Stomatol. 1999 Jan-Feb;48(1-2):23-8. [PubMed]

Cite as: Borg B, Knepler J. Medical image of the week: mediastinal lipomasosis. Southwest J Pulm Crit Care. 2018;16:228-9. doi: https://doi.org/10.13175/swjpcc046-18 PDF 

Medical Image of the Week: Dobhoff Tube Placement with Roux-En-Y Gastric Bypass

Figure 1. Abdominal X-ray after Dobhoff tube (DHT) placement to confirm accurate positioning. The distal tip of the feeding tube is in a loop of jejunum in patient status post gastrojejunostomy.

Figure 2. Gastrointestinal anatomy before and after Roux-en-Y gastric bypass procedure.

Roux-en-Y gastric bypass is one of the most commonly performed bariatric operations in the United States.  It involves partitioning a small gastric pouch off the proximal stomach and attaching that pouch directly to the intestine, thereby bypassing the large remainder of the stomach (1,2). Placing a Dobhoff tube (DHT) and confirming its placement can be challenging due to the change in anatomy after the procedure. Here, we have a 65-year-old woman who presented to the hospital with acute encephalopathy and acute hypoxic respiratory failure due to multifocal pneumonia requiring intubation and prolonged ICU stay. A DHT was inserted after intubation for feeding purposes. An abdominal X-ray was obtained to confirm placement of the DHT (Figure 1).  Normally the DHT tip should be placed in the 2^nd to 3^rd portion of the duodenum and would create a C-shaped tracing on the X-ray. However, in our patient who had history of Roux-en-Y, the DHT bypassed the duodenum and went straight down from the stomach to the jejunum as illustrated in Figure 1. It is important to be aware of this change in anatomy in patients who had a Roux-en-Y gastric bypass surgery in order to confirm accurate placement of DHT.

Hasan Ali¹ MD, Huthayfa Ateeli² MBBS, Bhupinder Natt²  MD FACP, and Sachin Chaudhary² MD.

¹Department of Medicine, Division of Internal Medicine and ²Division of Pulmonary, Critical Care, Sleep and Allergy

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Smoot TM, Xu P, Hilsenrath P, Kuppersmith NC, Singh KP. Gastric bypass surgery in the United States, 1998–2002. Am J Public Health. 2006;96(7):1187–9. [CrossRef] [PubMed]
2. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294(15):1909–17. [CrossRef] [PubMed]

Cite as: Ali H, Ateeli H, Natt B, Chaudhary S. Medical image of the week: Dobhoff tube placement with Roux-en-Y gastric bypass. Southwest J Pulm Crit Care. 2018;16(4):226-7. doi: https://doi.org/10.13175/swjpcc045-18 PDF