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Esophageal Rupture

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841. Spinal Dysraphism/Myelomeningocele

, is suggestive of a dermoid inclusion cyst. A suspected dermoid inclusion cyst should be carefully evaluated for any associated skeletal dysraphism, fibrous band, or sinus tract leading to the surface of the skin. Accidental or iatrogenic rupture of a dermoid may be diagnosed when characteristic lipid droplets are seen in the subarachnoid spaces of the sulci and cisterns. Previous Next: Magnetic Resonance Imaging Mangels and associates showed that fetal MRI is an effective, noninvasive means of assessing (...) of all ages; however, they account for about 10% of tumors in patients younger than 15 years. They may be associated with a dermal sinus or occur in isolation. When not associated with dermal sinuses, they may occur with progressive compressive myelopathy or with chemical meningitis of acute onset; such compression is caused by the rupture of the cyst and the spread of cholesterol crystals in the CSF. The thoracic lumbar and sacral spine are affected; there is a slight increase in incidence

2014 eMedicine Radiology

842. Pneumothorax

, right-sided pneumothorax has occurred from a rupture of a subpleural bleb. A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the pleural line. Spontaneous pneumothorax may be either primary (occurring in persons without clinically or radiologically apparent lung disease) or secondary (in which lung disease is present and apparent). Most individuals with primary spontaneous pneumothorax (PSP) have unrecognized lung disease (...) ; many observations suggest that spontaneous pneumothorax often results from rupture of a subpleural bleb. [ , , , , ] In a study of spontaneous pneumothorax in 55 children, 9 had visible bullae on initial radiograph, and apical emphysematous-like changes (ELC) were identified in 37 children by CT. The most successful surgical approach was thoracoscopic staple bullectomy and pleurectomy. [ ] In neonates with pneumothorax, [ , , ] ultrasound has been found in some studies to be comparable to chest

2014 eMedicine Radiology

843. Portal Hypertension

abdominal radiograph may indicate PH. An upper GI tract barium series is often performed for the detection of esophageal varices. (See the images below.) Barium swallow in the left lateral decubitus position shows multiple mucosal nodules in the mid to lower esophagus. In a patient with cirrhosis, these are suggestive of esophageal varices. Doppler sonogram at the splenic hilum reveals hepatofugal venous flow in a patient with portal hypertension. Barium swallow in a 56-year-old man with known cirrhosis (...) signs of portal hypertension (PH) that may be shown on plain radiographs. Signs of underlying liver disease may be noted, such as splenomegaly and ascites. Portal hypertension is displayed in the radiographic images below. Barium swallow in the left lateral decubitus position shows multiple mucosal nodules in the mid to lower esophagus. In a patient with cirrhosis, these are suggestive of esophageal varices. Barium swallow in a 56-year-old man with known cirrhosis who had a recent episode

2014 eMedicine Radiology

844. Pancreatitis, Chronic

. Plain abdominal radiograph shows a common bile duct stent in situ and fairly extensive pancreatic calcification. Upper GI tract barium series Even in the age of cross-sectional imaging, upper GI tract barium series may provide information that is critical to the treatment of patients with chronic pancreatitis. Esophageal involvement rarely occurs in chronic pancreatitis, and obstruction is usually the result of mediastinal extension of a pseudocyst. Pancreatic enlargement or a pseudocyst may (...) and in the quality of CT scanners. CT helps in the diagnosis of atrophy of the pancreas, providing better results than ultrasonography. Pancreatic pseudocysts and complications associated with pseudocysts, including various organ involvements, infection, hemorrhage with pseudoaneurysm formation, rupture with fistula formation, and gastrointestinal or biliary obstruction, are well depicted on CT. Detection of these complications are important, as they may necessitate prompt intervention or surgery. [ , ] False

2014 eMedicine Radiology

845. Cold Injuries

placement. An inaccurate reading may result if the rectal probe was inserted in cold feces or to a depth of less than 15 cm. Other methods of determining core body temperature include infrared tympanic thermometers, esophageal probes in intubated patients, and bladder thermistors embedded in a urinary catheter. The tympanic probe accurately measures hypothalamic temperature and most rapidly changes to reflect variations in core body temperature. On the basis of temperature measurements, the arbitrary (...) intracellular dehydration. The cell content becomes hyperosmolar, and toxic concentrations of electrolytes may cause cell death. [ ] Usually, no gross rupture of the cell membrane is evident. A reversal of this process probably occurs during thawing of frozen tissues. After tissue thawing, vasodilation and leakage from capillaries occur, causing tissue edema. This edema can often be quite marked and alarming to practitioners who do not expect this normal response. Alternating freeze-thaw cycles potentiate

2014 eMedicine Surgery

846. Cancer of the Hypopharynx

) and the esophageal inlet below (at the lower end of the cricoid cartilage). Embryologically, the larynx interjects into the hypopharynx anteriorly and is therefore considered a separate structure. Hypopharyngeal cancers are often named for their location, including pyriform sinus, lateral pharyngeal wall, posterior pharyngeal wall, or postcricoid pharynx (see images below). Most arise in the pyriform sinus. In the United States and Canada, 65-85% of hypopharyngeal carcinomas involve the pyriform sinuses, 10-20 (...) on retaining the ability to talk, chemoradiotherapy was chosen. See the list below: Tumor invasion often causes a combination of painful swallowing (odynophagia) and neuromuscular dysfunction (dysphagia). Patients frequently report food sticking in the upper esophagus or upper throat; this is because the hypopharynx is involved in the coordination of the swallowing function around the larynx. Aspiration is occasionally seen. Weight loss and malnutrition are common at presentation. Otalgia: Referred pain

2014 eMedicine Surgery

847. Deep Neck Infections

to the oral cavity and pharynx (eg, gun shot wounds, pharynx injury caused by falls onto pencils or Popsicle sticks, esophageal lacerations from ingestion of fish bones or other sharp objects) Instrumentation, particularly from esophagoscopy or bronchoscopy Foreign body aspiration Cervical lymphadenitis Branchial cleft anomalies Thyroglossal duct cysts Thyroiditis with petrous apicitis and Bezold abscess Laryngopyocele IV drug use [ ] Necrosis and suppuration of a malignant cervical lymph node or mass (...) the parotid and masticator spaces. The middle layer of the deep cervical fascia has 2 divisions, muscular and visceral. The muscular division surrounds the strap muscles (ie, sternohyoid, sternothyroid, thyrohyoid, omohyoid) and the adventitia of the great vessels. The visceral division surrounds the constrictor muscles of the pharynx and esophagus to create the buccopharyngeal fascia and the anterior wall of the retropharyngeal space. Both the muscular and visceral divisions contribute to the formation

2014 eMedicine Surgery

848. Congenital Malformations, Trachea

arches. A pulmonary artery sling is also known as an aberrant left pulmonary artery. In these cases, the left pulmonary artery passes between the trachea and esophagus, resulting in distal tracheal and right bronchus compression (see the video below). It is associated with the presence of complete tracheal rings. Barium swallow or rigid esophagoscopy study reveals anterior esophageal compression (in contrast to posterior esophageal compression with a double aortic arch). Treatment involves surgical (...) , with 50% associated with other malformations. The incidence is thought to be 1 in 2500 to 4500 live births. Associated symptoms include VACTERL, CHARGE, Fanconi anemia, Opitz G, and Goldenharr. Various degrees of esophageal atresia with or without associated fistula connection to the trachea prevent egress of saliva and feed into the stomach and provide direct connection between esophagus/gastric contents with the tracheobronchial tree. The Ladd and Gross classification is used to describe the anatomy

2014 eMedicine Surgery

849. Considerations in Pediatric Trauma

. There are 3 horizontal zones of the neck for classification of injury location. Zone 1 extends from the sternal notch to the cricoid cartilage. Zone 2 extends from the cricoid cartilage to the angle of the mandible. Zone 3 extends from the angle of the mandible to the skull base. Angiography, endoscopy, and bronchoscopy are useful for a complete examination. Missed esophageal injury can be greatly minimized by endoscopy, esophagram, and careful physical examination. A 5-year retrospective study (...) , the full adult complement of pulmonary alveoli is not present until about age 7 years.) If a rupture of the globe is suspected, the examination should cease; the eye should be covered with a protective device, and urgent ophthalmologic consultation is indicated. In evaluation of a foreign body, topical anesthetic may be useful for a complete examination. The lid should be everted with a cotton swab for a thorough evaluation. Examination should include an assessment of visual acuity and extraocular

2014 eMedicine Surgery

850. Congenital Malformations, Neck

. On the right side, the tract passes underneath the subclavian artery and courses superior to the recurrent laryngeal nerve and inferior to the superior laryngeal nerve. On the left side, the tract passes anteriorly underneath the aorta and courses superiorly in the neck, posterior to the common carotid artery. Fourth branchial anomalies often terminate in the perithyroid space, thyroid gland, or cervical esophagus, and they may manifest clinically as an abscess in these areas. The cutaneous opening (...) syndrome, neurofibromatosis, and Hodgkin lymphoma, although this is quite rare. Patients may also present with , which is associated with neoplasms of the thymus. Transudative pleural effusion due to rupture of a thymic cyst into the pleural cavity is very rare. This was recently documented in a patient who reported chest pain in the right hemithorax and dyspnea on exertion. Previous Next: Sternocleidomastoid Tumor of Infancy Sternocleidomastoid tumor of infancy (SCTI) is part of the spectrum

2014 eMedicine Surgery

851. Empyema and Bronchopleural Fistula

abscesses, a ruptured esophagus, mediastinitis, osteomyelitis, pericarditis, cholangitis, and diverticulitis, among others. Bacteriology Bacteriologic features of culture-positive parapneumonic pleural effusions have changed over time. Prior to the antibiotic era, Streptococcus pneumoniae was the most common. S pneumoniae and Staphylococcus aureus now account for approximately 70% of aerobic Gram-positive cultures. Presently, aerobic organisms are isolated slightly more frequently than anaerobic (...) and Gram-negative bacteria. Trauma can also lead to inoculation and superinfection of the pleural space. In the absence of trauma or surgery, the infecting organism may have spread from blood or other organs into the pleural space. These causes include extension of infections from adjacent or distant sites (eg, ruptured esophagus, mediastinitis, osteomyelitis, pericarditis, cholangitis, diverticulitis, pericarditis) or subdiaphragmatic abscesses. Risk factors Risk factors for empyema thoracis include

2014 eMedicine Surgery

852. Hookworm (Treatment)

their adult form. The buccal capsule of an adult A duodenale has teeth to facilitate attachment to mucosa, whereas an adult N americanus has cutting plates instead. A muscular esophagus creates suction in the buccal capsule. Using their buccal capsule, the adult worms attach themselves to the mucosal layer of the proximal small intestine, including the lower part of the duodenum, jejunum, and proximal ileum (see the image below). In so doing, they rupture the arterioles and venules along the luminal

2014 eMedicine Emergency Medicine

853. Fracture, Clavicle (Treatment)

are on the distal segment, while the proximal segment, without ligamentous attachments, is displaced. A type IIB fracture of the distal clavicle. The conoid ligament is ruptured, while the trapezoid ligament remains attached to the distal segment. The proximal fragment is displaced. The Neer type II fracture was later divided into types IIA and IIB, as follows (see the images below): Type IIA - Displaced due to fracture medial to the coracoclavicular ligaments; the conoid and trapezoid remain attached (...) or for backpackers. If a donut pad is not sufficient to relieve symptoms, surgical excision can be considered. Posttraumatic arthritis can develop if a clavicle fracture enters the AC or SC joints. Complications after group III fractures (medial third of the clavicle) resemble those associated with posterior sternoclavicular dislocations, including pneumothorax and compression or laceration of the great vessels, trachea, or esophagus. Mortality While the overwhelming majority of clavicle fractures are benign

2014 eMedicine Emergency Medicine

854. Foreign Bodies, Gastrointestinal (Treatment)

to be a problem in the United States, with increasing frequency, most commonly in children with an average age of around 4 years. [ , ] The presence of a button battery in the esophagus is a medical emergency because necrosis of the esophageal wall may occur within 2 hours. [ ] These batteries range from 7-25 mm and are radiopaque. On radiographs, they appear as round densities, similar to an ingested coin, but some demonstrate a "double-contour" configuration. It is important to distinguish between a coin (...) poisoning. Button batteries lodged in the esophagus must be removed immediately. Removal options include endoscopy, Foley catheter removal, esophageal bougienage, or Magill forceps removal. Intact button batteries in the stomach are safe and can be allowed to pass but must be monitored radiographically to observe for disruption of the battery. Follow-up radiographs are needed in 24-48 hours. If the battery is still in the stomach, endoscopic removal is indicated. Patients in a stable condition

2014 eMedicine Emergency Medicine

855. Foreign Bodies, Nose (Treatment)

balloon is firmer and theoretically less prone to rupture. Regardless of catheter type, the technique is similar. First, the balloon is inspected, and the catheter is coated with 2% lidocaine jelly. Then, with the patient lying supine, it is inserted past the foreign body and inflated with air or water (2mL in small children and 3mL in larger children). After inflation, the catheter is withdrawn, pulling the foreign body with it. (See the illustration below.) Use of a Fogarty catheter to remove (...) " [ , ] ) or a bag-valve mask. With either method, a tight seal is formed around the child's mouth, while avoiding the nose. The unaffected nostril is then occluded, and a forceful puff of air is provided. When the bag-valve mask is used, the Sellick maneuver can be considered to prevent esophageal air insufflation. [ ] If these techniques do not completely remove the object, they may at least dislodge the object more anteriorly and allow for removal using the previously described techniques. Another positive

2014 eMedicine Emergency Medicine

856. Pneumothorax, Tension and Traumatic (Treatment)

factors, and outcome. Anesthesiology . 2006 Jan. 104(1):5-13. . Miller JS, Itani KM, Oza MD, Wall MJ. Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation. Ann Emerg Med . 1997 Sep. 30(3):343-6. . Hashmi S, Rogers SO. Tension pneumothorax with pneumopericardium. J Trauma . 2003 Jun. 54(6):1254. . Iannoli ED, Litman RS. Tension pneumothorax during flexible fiberoptic bronchoscopy in a newborn. Anesth Analg . 2002 Mar. 94(3):512-3; table of contents

2014 eMedicine Emergency Medicine

857. Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum (Treatment)

factors, and outcome. Anesthesiology . 2006 Jan. 104(1):5-13. . Miller JS, Itani KM, Oza MD, Wall MJ. Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation. Ann Emerg Med . 1997 Sep. 30(3):343-6. . Hashmi S, Rogers SO. Tension pneumothorax with pneumopericardium. J Trauma . 2003 Jun. 54(6):1254. . Iannoli ED, Litman RS. Tension pneumothorax during flexible fiberoptic bronchoscopy in a newborn. Anesth Analg . 2002 Mar. 94(3):512-3; table of contents

2014 eMedicine Emergency Medicine

858. Pleural Effusion (Treatment)

of conditions, including empyema; rheumatoid, tuberculous, or lupus pleuritis; malignancy; urinothorax; or esophageal rupture. [ ] Cytologic analysis ­- Especially if malignancy is suspected. In the appropriate clinical setting, Gram staining, acid­-fast bacilli staining, and culture and sensitivity for aerobic and anaerobic organisms and fungi. Additional studies should be requested on the basis of the gross appearance of the pleural fluid or when a specific condition is suspected. Procalcitonin and C (...) of the ipsilateral lung. Bilateral effusions with an enlarged cardiac silhouette are most likely due to congestive heart failure. In the absence of cardiomegaly, malignancy (either lymphoma or carcinoma, with the exception of breast and lung cancer) is the most common cause. Other possible etiologies include the following: Lupus pleuritis Rheumatoid pleurisy Nephrotic syndrome Cirrhosis with ascites Pulmonary embolism TB Esophageal rupture Benign asbestos pleural effusion Meigs syndrome Uremic pleuritis Yellow

2014 eMedicine Emergency Medicine

859. Neck Trauma (Treatment)

in the aerodigestive tract, hemoptysis, and/or hematemesis New-onset bruit Previous Next: Medical Care Observe patients with all but the most trivial of neck wounds for delayed onset of symptoms. Platysma violation usually justifies admission for 24 hours of observation to avoid missing occult injuries, particularly vascular and esophageal wounds. Decisions regarding the need to admit a patient with blunt neck trauma are based on the presence or absence of signs and symptoms as well as the patient's underlying (...) , blood, vomitus) is always a possibility. Patients who survive the initial strangulation injury may succumb to pulmonary edema or bronchopneumonia. Unrecognized vascular injury may lead to delayed exsanguination (rupture of clot with hemorrhage), clot embolization or thrombosis, and/or formation of a false channel (pseudoaneurysm) or arteriovenous fistula, which can both evolve into delayed hemorrhage. Vascular injuries subsequent to blunt trauma specifically are associated with a high complication

2014 eMedicine Emergency Medicine

860. Mitral Valve Prolapse (Treatment)

supplementation. Am J Cardiol . 1997 Mar 15. 79 (6):768-72. . Scordo KA. Mitral valve prolapse syndrome: interventions for symptom control. Dimens Crit Care Nurs . 1998 Jul-Aug. 17 (4):177-86. . Fontana ME, Sparks EA, Boudoulas H, Wooley CF. Mitral valve prolapse and the mitral valve prolapse syndrome. Curr Probl Cardiol . 1991 May. 16 (5):309-75. . Kao CH, Tsai SC, Hsieh JF, Ho YJ, Ding HJ. Radionuclide esophageal transit test to detect esophageal disorders in patients with mitral valve prolapse (...) . 149 (11):787-95. . Yanase Y, Ishikawa N, Watanabe M, Kimura S, Higami T. Mitral valve plasty for idiopathic rupture of mitral valve posterior chordae in infants. Ann Thorac Cardiovasc Surg . 2014. 20 (2):150-4. . Turker Y, Ozaydin M, Acar G, et al. Predictors of atrial arrhythmias in patients with mitral valve prolapse. Acta Cardiol . 2009 Dec. 64 (6):755-60. . Turker Y, Ozaydin M, Acar G, et al. Predictors of ventricular arrhythmias in patients with mitral valve prolapse. Int J Cardiovasc Imaging

2014 eMedicine Emergency Medicine

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