대한흉부영상의학회 Weekly Chest Cases

Case No : 946 Date 2015-12-14

Courtesy of Jeong Jae Kim, Sun Young Jeong / Jeju National University Hospital
Age/Sex 71 / F
Chief ComplaintChest pain and fever (onset: 6 days ago) with a history of steroid intake for 4 months

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Diagnosis With Brief Discussion

Diagnosis: Acute phlegmonous esophagogastritis
Radiologic Findings: Enhanced CT scans show diffuse wall thickening with intramural low density area in the whole length of esophagus and the gastric cardia. Intramural low density area is surrounded by peripheral enhancing rim. At the level of aortic arch, a small air bubble is seen inside the thickened esophageal wall. Barium esophagogram shows multiple mucosal defects and extraluminal barium collection along the long axis of esophagus.
Brief Review: Phlegmon is a spreading diffuse inflammatory process associated with the formation of a suppurative exudate or pus. Phlegmonous infection can affect any site of the gastrointestinal tract, although the stomach is most frequently involved. Simultaneous involvement of esophagus and stomach is rare. Phlegmonous infection usually involves the submucosa and not the mucosa; inflammation may involve the muscularis mucosa and the serosa and lead to perforation. Phlegmonous gastritis may be either localized or diffuse.

The pathogenesis of acute phlegmonous esophagitis is unclear. Reported predisposing factors include immune suppression, alcoholism, peptic ulcer disease, chronic gastritis or some other gastric mucosal injury, achlorhydria, infection, connective tissue disease, and malignancy. Presumably, these conditions predispose the stomach to infection by eliminating various defense mechanisms, such as inherent gastric cytoprotection or bactericidal effect of gastric acid. Nevertheless, approximately 50% of reported cases were on previously healthy patients with no significant anteceding risk factors.

CT findings of phegmonous esophagitis or gastritis are diffuse esophageal and gastric wall thickening with circumferential intramural low density areas. Area of intramural low attenuation surrounded by a peripherally enhancing rim represents intramural abscess. Air bubbles in the thickened esophageal wall seen on CT may have been produced by gas-forming organisms (indicating emphysematous esophagogastritis) or entered the wall when the intramural abscess spontaneously drained into the lumen.
The radiographic differential diagnoses include dissecting intramural hematoma and tubular duplication of esophagus. However, the clinical symptom of dissecting intramural hematoma is chest pain with no evidence of infection or inflammation, and patients with tubular duplication are unlikely to have symptoms or signs.

Antibiotic therapy and surgical drainage are effective treatments for acute phlegmonous esophagitis depending on the clinical situation. Protracted conservative treatment results in surgical resection due to the possibilities of esophageal necrosis, esophageal stricture, gastric mucosal atrophy, and complicated peritonitis. Therefore, awareness of this disease entity and prompt diagnosis based on typical chest CT findings are major key factors to successful treatment.
References: 1. Jung C et al. Acute Diffuse Phlegmonous Esophagogastritis: Radiologic Diagnosis. American Journal of Roentgenology. 2003;180:862-863
2. Kim HS et al. Acute Diffuse Phlegmonous Esophagogastritis: A Case Report. J Korean Med Sci. 2010; 25(10): 1532
Keywords: Esophagus, Infection, Bacterial infection,

No. of Applicants : 86

▶ Correct Answer : 34/86, 39.5%

- Juntendo University Hospital , Japan Akifumi Hagiwara
- Kyoto University , Japan Akihiko Sakata
- SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
- Wuhan Union Hospital , China Qiguang Cheng
- Kyungpook national university , Korea (South) Chungeun Lim
- Gangnam Severance Hospital , Korea (South) Chul Hwan Park
- MBAL BURGAS , Bulgaria VLADISLAV RUSINOV
- ROKAF 10th Fighter Wing , Korea (South) Kun Woo Kang
- VHS medical center , Korea (South) Seong hee Jeon
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- IRSA La Rochelle , France Denis Chabassiere
- Asan Medical Center , Korea (South) Jooae Choe
- University of Tsukuba Hospital , Japan Hiroaki Takahashi
- Niigata City General Hospital , Japan Takao Kiguchi
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- privato , Italy genchi enzo
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- KEM ,MUMBAI , India SHAH ALAM
- Ishikawa Matto Central Hospital , Japan Manabu Akimoto
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- 異⑸ , Korea (South) Yunhee Jang
- chonnam national university hospital , Korea (South) Kim go eun
- DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
- Hanam sungshim hospital , Korea (South) CHANG IL KIM
- Okinawa Kyodo Hospital , Japan Shoko Iraha
- Asan , Korea (South) Sania ALBlushi
- the first affiliatited hospital of nanjing medical univercity , China Hai Xu
- National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
- Asan Medical Center , Korea (South) , Korea (South) Han Na Lee
- Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- CLCC Rennes , France nicolas gautier
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou

▶ Correct Answer as Differential Diagnosis : 3/86, 3.5%

- Okayama University Hospital , Japan Toshiyuki Komaki
- CNUH , Korea (South) LEE JAE
- Kizawa Memorial Hospital , Japan Yo Kaneko

▶ Semi-Correct Answer : 2/86, 2.3%

- Northern Yokohama Showa university , Japan Kota Watanabe
- The University of Tokyo Hospital , Japan Takeyuki Watadani

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 946 Date 2015-12-14

Discussion

No. of Applicants : 86