Esophageal Duplication Cyst

Esophageal Duplication Cyst: A Rare Obstacle to Transesophageal Echocardiography SCIPIONE CARERJ, M.D., MARIA PAOLA TRIFIRO, M.D., ANDREA ODDO, M.D., VINCENZO LUCISANO, M.D., and GIUSEPPE ORETO, M.D. Department of Internal Medicine, University of Messina, Messina, Italy

A 58-year-old man was admitted to the hospital with chest pain progressively worsening during the last 2 days and without any other significant symptom; in particular, there was no dysphagia. The physical examination was normal apart from hypotension associated with cold sweating; his blood pressure was 90/50 mmHg in the right arm and 60/40mmHg in the left arm. Laboratory data demonstrated anemia (hemoglobin 9 g/dl). The electrocardiogram did not show any abnormality, whereas the chest radiograph reflected a widened mediastinum. Aortic dissection was suspected, and the patient underwent transesophageal echocardiography (TEE) after the administration of intravenous diazepam (10 mg). The examination revealed a large echodense mass that was placed in the posterior mediastinum between the transducer and the heart so that analysis of cardiac structures was impossible (Fig. 1A). Progression of the probe through the lower third of the esophagus was difficult, so no attempt was made to obtain gastric views on TEE. A computed tomography scan of the thorax demonstrated a cystic structure continuous with the esophageal wall (Fig. 2A). The esophagus was compressed and dislocated to the left. The structure had a tubular morphology and occupied the entire posterior mediastinum. Magnetic resonance imaging confirmed these data and also showed a subacute intramass hemorrhage (Fig. 2B). The patient underwent surgery; an esophageal cyst was found and reAddress for correspondence and reprints: Scipione C a r e j , M.D., Via Campo delle Vettovaglie, 10, 98122 Messina, Italy. Fax: 39-90-693917.

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sected. The pathology report described an “esophageal duplication cyst.” The results of postsurgery TEE were normal (Fig. 1B).

Figure 1. (A) Transesophageal transverse plane image demonstrates a large echodense mass (C) placed between the esophagus and the heart in such a way that analysis of the cardiac structures is irnpossible. (B) The same image after resection of the esophageal duplication cyst. The cardiac structures are clearly seen. A 0 = aorta; L A = left atrium; RA = right atrium.

ECHOCARDIOGWHY: A Jrnl. of CV Ultrasound & Allied Tech.

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Discussion Esophageal duplication cyst usually is diagnosed in childhood, but it also may be unrecognized in the absence of complications. In the present case, the patient became symptomatic because of the intramass hemorrhage, resulting in distension of the cystic wall and chest pain. The cause of hemorrhage is unknown: no history of chest trauma or forceful vomiting was present. The clinical picture of esophageal duplication cyst is variable on the basis of location and size. Symptoms include dysphagia, epigastric discomfort, chest pain, dyspnea, cough, and neck vessel distention, with possible difference in blood pressures between the right and left arms due to compression of a subclavian artery by the cyst.” The esophageal duplication cyst, extending through the entire posterior mediastinum, did not allow visualization of cardiac structures from an esophageal point of view. Other situations, such as the paraesophageal hernia, can prevent adequate transesophageal imaging of cardiac s t r u c t u r e ~ . ~ In our case, TEE was the first imaging technique leading t o the suspicion of an esophageal duplication cyst, which was confirmed through computed tomography scanning, magnetic resonance imaging, and pathological examination.

References Figure 2. (A)Computed tomography scan depicting a large cystic mass CC) in the posterior rnediastinum. The esophagus (E) cannot be dissociated from the wall of the lesion (arrows) and is compressed and dislocated. The aorta (A01 is dislocated laterally and posteriorly. (B) Coronal T 1-weighted magnetic resonance image showing the tubular morphology of the lesion ICI whose content is markedly hyperintense.

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1 Salo JA, Ma-Kuliu KV: Congenital esophageal cyst in adults. Ann Thorac Surg 1987;44:135-138. 2. Rafal RB, Markisz JA: Magnetic resonance imaging of an esophageal duplication cyst. Am J Gastroenterol 1991;86:1809-1811. 3. Freedberg RS, Weinreb J, Gluck M, et al: Paraesophageal hernia may prevent cardiac imaging by transesophageal echocardiography. J Am SOC Echocardiogr 1989;2:202-203.

ECHOCARDIOGRAPHY: A Jml. of CV Ultrasound & Allied Tech.

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