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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 12-14

Multiphasic contrast study in chest: Is it required?


1 Department of Radiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
2 Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India

Date of Web Publication23-Dec-2015

Correspondence Address:
Phani Chakravarty Mutnuru
Department of Radiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.159881

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  Abstract 

Contrast-enhanced multidetector computed tomography scan is most widely used technique in the assessment of various thoracic pathologies. The role of triphasic study in the evaluation of abdominal pathologies, mainly liver, is well-known, but for chest pathologies are not yet well-established. We report a case of cirrhosis of the liver with the mediastinal lesion, investigations done for diagnosis and role of multiphasic study in picking up final diagnosis. Hence, it is suggested, even though, multiphasic study is not routinely done, sometimes it will be helpful in the diagnosis of tricky chest lesions.

Keywords: Chest, multiphasic contrast study, paraesophageal varices


How to cite this article:
Mutnuru PC, Padmani SU, Patnaik S, Manasa PL. Multiphasic contrast study in chest: Is it required?. J Assoc Chest Physicians 2016;4:12-4

How to cite this URL:
Mutnuru PC, Padmani SU, Patnaik S, Manasa PL. Multiphasic contrast study in chest: Is it required?. J Assoc Chest Physicians [serial online] 2016 [cited 2021 Dec 7];4:12-4. Available from: https://www.jacpjournal.org/text.asp?2016/4/1/12/159881


  Introduction Top


The role of multiphasic contrast study and contrast injection protocols are well-established while evaluating abdominal pathologies, especially hepatic pathologies. The role of multiphasic study in the chest is limited so far for few conditions, and limited literature is available. We report a mediastinal lesion, which was diagnosed in the venous phase of triphasic study while evaluating abdomen.


  Case Report Top


A 45-year-old male patient, known case of hepatitis B +ve with cirrhosis presented with complaints of mild abdominal pain and difficulty in swallowing since 3 months. Initially, he was evaluated in one of the peripheral hospitals. Ultrasound of abdomen was done and showed features of cirrhosis with multiple mixed to slightly echogenic hepatic lesions and multiple collaterals in the abdomen with splenomegaly. Contrast-enhanced computed tomography (CECT) abdomen was done and showed very minimally enhancing lesions in the liver with multiple collaterals and one heterogeneously enhancing lesion in the lower paraesophageal region on the right side with minimal compression of lower esophagus. He was referred to our institute with a diagnosis of the possibility of hepatocellular carcinoma and leiomyoma of lower esophagus/lymphnodal mass.

In our institute, he underwent upper gastrointestinal (GI) endoscopy and triphasic CECT scan of the abdomen including lower chest. Multiple lower esophageal varices were seen with endoscopy and extrinsic compression over lower esophagus noted. CECT abdomen revealed multiple liver lesions showing peripheral and nodular enhancement in the arterial phase with gradual centripetal enhancement in venous phase and completely enhancing in equilibrium phase suggestive of hemangiomas [Figure 1]. There is one lesion in the lower paraesophageal region on the right side showing heterogeneous enhancement in the arterial phase, but in venous phase there were multiple paraesophageal varices [Figure 2]. Other findings were consistent with ultrasound findings. His alpha-fetoprotein levels were within normal limits. He is presently under treatment.
Figure 1: Multidetector computed tomography triphasic study: (a) Plain scan shows well-defined, hypodense lesion in left lobe of liver, (b) arterial, (c) portal and (d) equilibrium phases show gradual filling of lesion with contrast

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Figure 2: Multidetector computed tomography triphasic study: (a) Topogram shows suspicious soft tissue density lesion in right paravertebral region in lower chest, (b) arterial phase axial section shows heterogeneously enhancing lesion in right lower paraesophageal region, (c) portal and (d) equilibrium phases show vascular nature of lesion

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  Discussion Top


The revolution in imaging technique over the past few decades has created a wide spectrum of choices for investigating patients with multiple pathologies in the body. Triphasic CECT involves imaging in arterial, venous, and equilibrium phases.[1] Recently, the arterial phase is subdivided into early and late arterial phases. After contrast administration, the early arterial phase is done at 15–20 s, late arterial phase at 35–40 s, venous or portal phase at 70–80 s, and equilibrium phase at 3–4 min.

Routine CECT chest protocol includes plain scan and post contrast imaging 30–40 s following injection. Chest angiographic protocol includes imaging by 15–20 s after bolus administration. These may vary by few seconds in different institutes/hospitals. So chances of missing venous pathologies are high.

Triphasic contrast study has already proved its diagnostic efficiency in abdominal pathologies, particularly liver diseases. In our case, multiple hepatic lesions were proved to be hemangiomas in a background of cirrhosis, thus eliminating the possibility of malignancy. Its role in the evaluation of chest pathologies is not yet well-documented but started gaining interest recently. In our case, the mediastinal lesion was proved to be paraesophageal varices in the venous phase.

So far, only a few articles are available in the literature about the role of multiphasic contrast study in the chest. Firstly-electrocardiography gated triphasic contrast study of the whole chest was being done to assess pulmonary arteries, coronary arteries, and thoracic aorta for evaluation of acute chest pain.[2] Multiphasic contrast study helps in proper opacification of all these vessels in different phases and various causes such as significant coronary artery stenosis, pulmonary embolus, aortic dissection, hypokinetic cardiomyopathy, lung parenchymal abnormalities, and hiatus hernia can be depicted as cause of chest pain.[3] Second, triphasic contrast study in patients with polytrauma results in a significantly increased diagnostic accuracy. It is helpful in delineating all vascular structures and parenchymatous organs simultaneously and differentiates between hematoma, ongoing arterial/venous bleeding and parenchymal contusions and lacerations.[4] Third, it is useful in the diagnosis of various vascular anomalies and vascular variants of chest both in adults and children.[5] Fourth, sometimes multiphasic contrast study is helpful in the diagnosis of miscellaneous/rare tumors in the chest such as granular cell tumor of trachea and hemangioma.[6]


  Conclusion Top


On nonenhanced CT scans, vascular lesions (in our case paraesophageal varices) may mimic soft tissue masses, enlarged lymph nodes or other GI tract abnormalities (e.g., leiomyoma, hiatal hernia). CECT scanning in arterial, portal, and equilibrium phases is essential for evaluating these lesions. Hence, it is suggested that if there is clinical suspicion of vascular pathology in the chest, multiphasic CECT scan is necessary for diagnosis and helps in avoiding unnecessary biopsy attempts.

 
  References Top

1.
Bialecki ES, Di Bisceglie AM. Diagnosis of hepatocellular carcinoma. HPB (Oxford) 2005;7:26-34.  Back to cited text no. 1
    
2.
Mitsumori LM, Wang E, May JM, Lockhart DW, Branch KR, Dubinsky TJ, et al. Triphasic contrast bolus for whole-chest ECG-gated 64-MDCT of patients with nonspecific chest pain: Evaluation of arterial enhancement and streak artifact. AJR Am J Roentgenol 2010;194:W263-71.  Back to cited text no. 2
    
3.
Bierry G, Roy C, Buy X, Kellner F, Jlassi H, Gangi A. ECG-gated chest CT angiography: Value for atypical chest pain evaluation. J Radiol 2009;90:825-31.  Back to cited text no. 3
    
4.
Loupatatzis C, Schindera S, Gralla J, Hoppe H, Bittner J, Schröder R, et al. Whole-body computed tomography for multiple traumas using a triphasic injection protocol. Eur Radiol 2008;18:1206-14.  Back to cited text no. 4
    
5.
Rodriguez A, Cobeñas R, Gallo JC, Salamida A, Larrañaga N, Kozima S. Incidental findings of vascular anatomic variants on computed tomography. Rev Argent Radiol 2013;77:1-7.  Back to cited text no. 5
    
6.
Guarnieri T, Cardinale L, Macchia G, Cortese G, Veltri A. Multiphasic multidetector computed tomography study of a rare tracheal tumor: Granular cell tumor. Case Rep Pulmonol 2014;2014.  Back to cited text no. 6
    


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  [Figure 1], [Figure 2]



 

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