A woman with intermittent heartburn
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1936 (Published 27 April 2017) Cite this as: BMJ 2017;357:j1936
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Dear Author / Dear Editor,
I read the above "spot-diagnosis" with interest.
Although my remit ends a lot of the time at age 4 weeks after birth, I retain a keen interest to maintain a broad overview of Medicine. This is why I trained first in adult and then retrained in Paediatric Surgery. And this is why, since Medical School almost 40 years ago, I still remember and practice well proven "rules" and "edicts" to make sure nothing is missed as far as humanly possible. This includes "The 5 steps of reviewing an X-ray" (briefly: technical, bones, soft tissues, visceral fields, other), which must have served many many Clinicians but more importantly countless Patients so well over the years. The second most important rule in radiography evaluation that was hammered into our plastic brains all these years ago is "never focus on the obvious abnormality".
Sadly, this "spot diagnosis" case you presented goes against every grain of methodological thoroughness: by focusing on the retrocardiac shadow, the observer would miss the slight misalignment of the film, the calcified opacity in the right upper zone, what looks like bilateral pleural effusions, increased perihilar opacities on the right and the abrupt, almost fusiform, interruption of the oesophageal gas shadow. Whether any of these individually or collectively can be related together or associated with the suspected condition (hiatus hernia), TB, neoplasia or other is not the case. The importance is that they are there, and if not picked up by systematic approach to the radiograph the Patient could be deprived of the open minded and thorough approach that they deserve. The presence of all these other abnormalities would have changed the ranking of conditions within the differential diagnosis (e.g. putting a malignant oesophageal stricture high on the list) and not following up on them could deprive the Patient of appropriate further investigations and early treatment. Furthermore, you corroborate the diagnosis of hiatus hernia on the basis of the absence of a normal gastric bubble; this is a weak conclusion, as - not only this is a "soft sign" depending on prandial status - the x-ray you presented does not cover the area appropriately to allow evaluation of the gastric shadow. Finally, the CT scan does not seem to take into consideration the need for evaluation of the rest of the chest x-ray abnormalities.
Protocols, procedures, checklists and the like have evolved to protect everyone and unless followed each time without cutting corners, every now and then something will be missed with possible consequences.
The most serious mistake of clever individuals is to interpret data in such a way in order to corroborate their pre-determined conviction. This comes at a great cost to the truth and the care of Patients. Let's not allow ourselves to fall in that trap ever.
Competing interests: No competing interests
Nice images, However if the patient presented with retrosternal heartburn, why do a chest radiograph? Often such hernias are detected as a coincidental finding on radiographs for other indications, but as we should be reducing the exposure of patients to radiation to a minimum, there does not seem any indication for doing the investigation. It would be wrong to suggest a chest X-ray is a useful or appropriate investigation for heartburn.
The discussion suggests that high-resolution manometry (HRM) is indicated in cases with gastro-oeosophageal reflux: this also seems incorrect. Although HRM can accurately define both the lower oesophageal sphincter and oesophageal dysmotility and is particularly useful in cases of dysphagia or recurrent heartburn with a normal endoscopy. In cases such as this with a large hiatal hernia, when associated with symptoms, oesophageal manometry really adds little to the management, which usually requires either acid suppression or consideration of surgical repair where safe and appropriate when dysphagic symptoms are mechanical due to the abnormal anatomy.
Competing interests: No competing interests
Re: A woman with intermittent heartburn
I thank Dr Hajivassiliou for his comment. From his response, we can tell he grasped a broad overview of medicine besides his speciality and has stuck to the well proven medical "rules" and "edicts" to make sure of the accuracy of medical practice and benefit to countless patients. I admire and respect his principle, and we should learn from him.
However, the suspicion of my practice interpreting the chest radiography going against the methodological thoroughness was groundless. Whenever reviewing a chest x-ray, I do use a systematic approach. The case emphasized the retrocardial zone because pathology in this area can easily be overlooked as I did encounter an inexperienced radiology trainee miss such an abnormality and it was meant to be a learning point for spot diagnosis readers. It doesn’t mean the observer (especially as a radiologist) would miss other signs on chest radiography listed by Dr Hajivassiliou. These findings would have been listed in the patient-care radiology report rather than in the article because this article was not intended to show how to interpret a chest x-ray systematically.
Back to the case radiography, the calcified opacity in the right upper zone stands for an old silent lesion most likely consistent with old TB; what looks like bilateral pleural effusions was Dr Hajivassiliou’s feeling as there’s no pleural effusion which can be confirmed on axial CT; increased perihilar opacities on the right was due to mild enlargement of pulmonary artery which is very common among old people. As for the abrupt, almost fusiform, interruption of the oesophageal gas shadow, I strongly doubt there was such a sign in the radiograph, what Dr Hajivassiliou saw should be the normal tracheal shadow.
Again, radiography evaluation requires both a systematic approach and experience along with repeated practice. I think spot diagnosis offers such a platform to discuss and practice.
Competing interests: No competing interests