Long evolution retrosternal pain

Clinical History

A 42-year-old male patient presented with a long evolution retrosternal pain and discomfort. He also complained of pyrosis.

Imaging Findings

A 42-year-old patient presented with a long evolution retrosternal pain and discomfort along with pyrosis. A chest plain film was taken. In the posteroanterior projection, the film showed that there was a morphological alteration of the right cardiac border, which presented a round appearance. The gas bubble corresponding to the gastric fundus was identified on an infradiaphragmatic location (Fig.1a). In the lateral projection, the presence of a mass on a posterior, retrocardiac, location was revealed (Fig. 1a, b). A transabdominal ultrasonographic examination in the longitudinal view was performed in the emergency room immediately after the chest film. The presence of a supradiaphragmatic mass, adjacent to the liver was identified. The mass, of rounded morphology, appeared filled with bright internal echoes, which resembled those of the contents of a digestive structure (Fig. 2a). A computed tomographic examination was performed after an intravenous contrast administration. The mass, that was located on the right posterior mediastinum, closely related to the esophagus, presented an internal fluid level and some areas of mural irregularity (Fig. 3a–c). An upper gastrointestinal barium tract study was also done, which confirmed the diagnosis of an epiphrenic diverticulum with abundant food rests, and demonstrated an area of mural irregularity, that the endoscopic biopsy showed to correspond to a carcinoma(Fig. 4a, b).

Discussion

An epiphrenic diverticulum is a rare disorder of the lower esophagus, thought to be related to an esophageal motility disorder. It is considered as a pulsion diverticulum, usually located on the right lateral wall of the distal esophagus, being multiple in some cases. This kind of diverticulum could reach a large size, and could present in all the layers of the esophageal wall. It is probably caused by a longstanding impairment of the esophageal motor activity and usually it is associated with reflux strictures or other lesions, and represents an unusual cause of dysphagia, pain and weight loss (1, 2). When this lesion reaches a large size, it could be demonstrated on the conventional chest plain film, usually as a retrocardiac mass. In this case, ultrasonography through a transabdominal approach, could play a role in an attempt to typify the nature of the lesion. The epiphrenic diverticulum is typically demonstrated by a computed tomography examination as a thin-walled, air- or air–fluid-filled structure communicating with the esophagus. However, those not associated with distal esophageal obstruction (stricture, achalasia) may remain contracted in the resting state and thus may not be visible. Occasionally, the diverticulum may have to be differentiated from a mediastinal abscess or tumors and even a hiatus hernia (3). The treatment of an epiphrenic diverticulum is surgical, but there is almost universal agreement to operate only on symptomatic patients, because the treatment has significant risks and is not warranted in patients with minimal symptoms because a progression of the is unlikely. The optimal treatment is controversial; the best accepted guideline is to treat the underlying motor disorder. There are some reports about surgical treatment through laparoscopy, that present favourable results about this new option of treatment (4). The majority of patients with carcinoma arising in an epiphrenic diverticulum are elderly males who have been symptomatic for years with a known diverticulum. It is important to considered the diagnosis of esophageal carcinoma early in the evaluation of patients with signs and symptoms suggestive of epiphrenic diverticula, as early intervention may be the only chance of cure (2, 5).

Differential Diagnosis List

Final Diagnosis

An epiphrenic esophageal diverticulum, with malignant transformation.

URL:	https://www.eurorad.org/case/3472
DOI:	10.1594/EURORAD/CASE.3472
ISSN:	1563-4086