2010 Radiology Exam - Spec Proced/NM Case 1

History

• 1-year Female English Bulldog
• Owner watched her choke on a chicken bone
• Regurgitates with water and food ever since
• rDVM administered 10 ml of barium liquid and made these radiographs.

Candidates were presented with orthogonal views of the neck and majority of the thorax. The VD view did not include the caudal-most aspect of the thorax.

See images below. Click to enlarge.

Observations

• Focal ventral and leftward deviation of the cranial thoracic esophagus, consistent with a redundant esophagus (common in the breed).
• Barium present mostly in the area of the esophageal redundancy, caudal esophagus, and stomach. Barium was also present around the mouth, on the skin, and in the larynx and oral cavity.
• No evidence of pneumonia or barium aspiration.
• Incidental caudal thoracic vertebral anomalies, also common to the breed.
• A mildly diffusely narrowed trachea that is likely within normal limits of the breed but unassociated with the current clinical signs.
• An exposed finger is under a lead glove, scruffing the dog to make the lateral projection.

Synthesis

• Redundant esophagus, mostly an incidental breed variant, though there are some reports of being associated with clinical signs.
• Otherwise inconclusive study for esophageal foreign body, esophagitis, or functional motility disorder of the esophagus.

Management

• Repeat radiographs, with more barium liquid, barium paste and mixed with food.
• Esophagram under fluoroscopy.
• Endoscopy depending on the findings of the added imaging.

Successful candidates were not penalized for identifying filling defects in the barium (mostly gas bubbles) that could be associated with an esophageal foreign body (survey images were not provided). However, they were expected to describe the limitations of the study as a point in time, needing additional images to appreciate persistence in filling defects or barium retention. Successful candidates described the redundant esophagus as common to the breed and did not make any strong, definitive diagnoses regarding esophagitis, foreign body, or motility disorders.

Unsuccessful candidates described the redundant esophagus as:

• a sign of stricture secondary to foreign body/esophagitis.
• a sign of functional motility disorder.
• a sign of esophageal stricture associated with a vascular ring anomaly.

Unsuccesful candidates also would describe the discrete cranial margin of barium outlining the caudal aspect of the upper esophageal sphincter as a filling defect associated with foreign body. These candidates simply failed to identify the upper esophageal sphincter and thought the area was abnormal. Unsuccessful candidates read the filling defects closely as definitive proof for foreign body (notably, a chicken foreign body). Unsuccessful candidates read the barium in the esophagus as a definitive sign of retention or gastroesophageal reflux, failing to describe the temporal limitations of the study for diagnosing such abnormalities.

At the end of this case, candidates were asked to describe the restraint technique used to make the lateral radiograph. Only one candidate described it without being asked. Many candidates failed to identify the fingers in the primary beam even after being asked. Many candidates thought the material was a sandbag placed next to the dog's head for restraint without any word regarding the restrainers fingers, the pulled skin from scruffing, or the issues of scatter from the table when a hand is under leaded material. This was not a large part of the question but it was interesting how few candidates noticed the human fingers, even after coaxing.

Overall, candidates did well on this question, the majority of which scored 8-9 out of 10 points