Imaging

Ankle effusions can be quite debilitating, causing band-like swelling and stiffness to the anterior aspect of ankle at the tibiotalar joint. Significant swelling can impair ankle dorsiflexion and plantar flexion. The differential diagnosis for joint effusions is wide, and includes traumatic effusion; gout; osteoarthritis; rheumatoid arthritis; and septic arthritis, which is one of the most important diagnoses for the emergency physician (EP) to identify and initiate prompt treatment to reduce the risk of serious morbidity and mortality. Differentiating these conditions requires joint aspiration and synovial fluid analysis. While a large effusion will be palpable and likely ballotable, smaller effusions are more challenging clinically. In such cases, point-of-care (POC) ultrasound can be a valuable tool in confirming a joint effusion.

Identifying Landmarks and Tibiotalar Joint

To access the tibiotalar joint space, it is important to identify useful landmarks.¹ This is best accomplished by having the patient in the supine position, with the affected knee flexed approximately 90° and plantar surface of the foot lying flat on the bed (Figure 1).

Performing the Arthrocentesis

The arthrocentesis is performed under sterile conditions using the high-frequency linear probe. A sterile probe cover is highly recommended if the operator will be using ultrasound to guide the procedure in real time.² Using the palpable landmarks as a guide, the clinician should align the probe just medial to the tibialis anterior tendon with the probe marker oriented cephalad; scanning should begin superior to the ankle joint. The tibia will appear as a hyperechoic stripe just under a thin soft tissue layer. When the tibia is visible, the clinician should then slide the probe distally. The joint space will demonstrated by visualization of the distal tibia and talus bone (Figure 3).

Pearls and Pitfalls

Point-of-care ultrasound is not only useful to guide arthrocentesis of joint effusions, but also to confirm the presence of an effusion prior to aspiration. At our institution, we have had many cases in which POC ultrasound demonstrated an absence of effusion, and we were able to avoid an unnecessary joint aspiration. Moreover, when an effusion is present, POC ultrasound-guided aspiration avoids complications. The use of POC ultrasound can also increase the confidence of the provider performing arthrocentesis of joints less commonly aspirated.

Summary

Joint aspiration is an important procedural tool for EPs, especially when used to rule out life-threatening conditions such as septic arthritis. Deeper joints and small fluid collections, however, can be difficult to access without image guidance. In the ED setting, POC ultrasound provides a widely available, easy-to-use, low-cost tool to increase the likelihood of success while minimizing damage to adjacent structures.

Ankle effusions can be quite debilitating, causing band-like swelling and stiffness to the anterior aspect of ankle at the tibiotalar joint. Significant swelling can impair ankle dorsiflexion and plantar flexion. The differential diagnosis for joint effusions is wide, and includes traumatic effusion; gout; osteoarthritis; rheumatoid arthritis; and septic arthritis, which is one of the most important diagnoses for the emergency physician (EP) to identify and initiate prompt treatment to reduce the risk of serious morbidity and mortality. Differentiating these conditions requires joint aspiration and synovial fluid analysis. While a large effusion will be palpable and likely ballotable, smaller effusions are more challenging clinically. In such cases, point-of-care (POC) ultrasound can be a valuable tool in confirming a joint effusion.

Identifying Landmarks and Tibiotalar Joint

To access the tibiotalar joint space, it is important to identify useful landmarks.¹ This is best accomplished by having the patient in the supine position, with the affected knee flexed approximately 90° and plantar surface of the foot lying flat on the bed (Figure 1).

Performing the Arthrocentesis

The arthrocentesis is performed under sterile conditions using the high-frequency linear probe. A sterile probe cover is highly recommended if the operator will be using ultrasound to guide the procedure in real time.² Using the palpable landmarks as a guide, the clinician should align the probe just medial to the tibialis anterior tendon with the probe marker oriented cephalad; scanning should begin superior to the ankle joint. The tibia will appear as a hyperechoic stripe just under a thin soft tissue layer. When the tibia is visible, the clinician should then slide the probe distally. The joint space will demonstrated by visualization of the distal tibia and talus bone (Figure 3).

Pearls and Pitfalls

Point-of-care ultrasound is not only useful to guide arthrocentesis of joint effusions, but also to confirm the presence of an effusion prior to aspiration. At our institution, we have had many cases in which POC ultrasound demonstrated an absence of effusion, and we were able to avoid an unnecessary joint aspiration. Moreover, when an effusion is present, POC ultrasound-guided aspiration avoids complications. The use of POC ultrasound can also increase the confidence of the provider performing arthrocentesis of joints less commonly aspirated.

Summary

Joint aspiration is an important procedural tool for EPs, especially when used to rule out life-threatening conditions such as septic arthritis. Deeper joints and small fluid collections, however, can be difficult to access without image guidance. In the ED setting, POC ultrasound provides a widely available, easy-to-use, low-cost tool to increase the likelihood of success while minimizing damage to adjacent structures.

Ankle effusions can be quite debilitating, causing band-like swelling and stiffness to the anterior aspect of ankle at the tibiotalar joint. Significant swelling can impair ankle dorsiflexion and plantar flexion. The differential diagnosis for joint effusions is wide, and includes traumatic effusion; gout; osteoarthritis; rheumatoid arthritis; and septic arthritis, which is one of the most important diagnoses for the emergency physician (EP) to identify and initiate prompt treatment to reduce the risk of serious morbidity and mortality. Differentiating these conditions requires joint aspiration and synovial fluid analysis. While a large effusion will be palpable and likely ballotable, smaller effusions are more challenging clinically. In such cases, point-of-care (POC) ultrasound can be a valuable tool in confirming a joint effusion.

Identifying Landmarks and Tibiotalar Joint

To access the tibiotalar joint space, it is important to identify useful landmarks.¹ This is best accomplished by having the patient in the supine position, with the affected knee flexed approximately 90° and plantar surface of the foot lying flat on the bed (Figure 1).

Performing the Arthrocentesis

The arthrocentesis is performed under sterile conditions using the high-frequency linear probe. A sterile probe cover is highly recommended if the operator will be using ultrasound to guide the procedure in real time.² Using the palpable landmarks as a guide, the clinician should align the probe just medial to the tibialis anterior tendon with the probe marker oriented cephalad; scanning should begin superior to the ankle joint. The tibia will appear as a hyperechoic stripe just under a thin soft tissue layer. When the tibia is visible, the clinician should then slide the probe distally. The joint space will demonstrated by visualization of the distal tibia and talus bone (Figure 3).

Pearls and Pitfalls

Point-of-care ultrasound is not only useful to guide arthrocentesis of joint effusions, but also to confirm the presence of an effusion prior to aspiration. At our institution, we have had many cases in which POC ultrasound demonstrated an absence of effusion, and we were able to avoid an unnecessary joint aspiration. Moreover, when an effusion is present, POC ultrasound-guided aspiration avoids complications. The use of POC ultrasound can also increase the confidence of the provider performing arthrocentesis of joints less commonly aspirated.

Summary

Joint aspiration is an important procedural tool for EPs, especially when used to rule out life-threatening conditions such as septic arthritis. Deeper joints and small fluid collections, however, can be difficult to access without image guidance. In the ED setting, POC ultrasound provides a widely available, easy-to-use, low-cost tool to increase the likelihood of success while minimizing damage to adjacent structures.

Anorectal and urethral foreign body insertions (polyembolokoilamania) are not infrequent presentations to the ED. The motivations behind these insertions vary, ranging from autoeroticism to reckless behavior. These insertions can lead to major complications and even death. Though ED staff members are used to the unpredictability of human behavior, foreign body insertions bring a mixture of responses from the staff, ranging from awe and incredulousness to anger and frustration. A knowledge and comfort in managing these cases includes a nonjudgmental triage assessment, collective professionalism, and self-awareness of the staff’s reaction.

Case 1

A 58-year-old man presented to the ED for evaluation of a foreign body in his rectum. He admitted to placing a beer bottle in his rectum, but was unable to remove it at home. The staff reported that the patient was previously seen in the ED for removal of a vibrator from his rectum.

Radiographic evaluation in the form of an acute abdominal series was obtained and confirmed a beer bottle in the rectum (Figures 1 and 2).

Case 2

A 55-year-old man presented to the ED after he inserted a pen cap into his urethra to aid in obtaining an erection. A pelvic X-ray was obtained and showed a radiolucent structure in the penis (Figure 3).

The patient was admitted to the hospital and taken to the OR by the consulting urologist. Using a rigid cystoscope and flexible graspers, the pen cap was removed from the proximal urethra under monitored anesthesia control. The procedure went without any complications.

A psychiatrist was consulted, and during the encounter, the patient admitted that his behavior was pathological. He revealed that he was a victim of child abuse and reported he had been having mixed emotions of anxiety, guilt, and embarrassment because of his behavior.

Discussion

Foreign body insertions are seen in patients with a wide variety of backgrounds, ages, and lifestyles. Approximately 80,000 cases of foreign body ingestion are seen annually in children under age 20 years. Young males have a higher predilection of swallowing foreign bodies when compared to young females,¹ and rectal foreign body insertions are seen more commonly in males than in females.² In this age group, intentional foreign body insertion may be an initial manifestation of psychiatric illness.

Rectal Insertions

The earliest published report of a rectal foreign body insertion was in 1919 by Smiley.⁶ The typical age at presentation ranges from 20 to 90 years old, with a mean age of 44 years old.² Household objects such as bottles and glasses are the most commonly seen, but a long list of other items have also been reported in the literature, including toothbrushes, knives, deodorant bottles, food articles, sports equipment, cell phones, flashlights, wooden rods, broomsticks, sex toys, light bulbs, construction tools, nails, ornaments, aerosol canisters, cocaine packets, jewelry, batteries, guitar picks, and many other items.^1,2,7

In nearly half of the reported cases, the reasons for rectal insertion was for sexual arousal/stimulation.^1,7 Other reasons include nonsuicidal injurious behavior (eg, borderline personality disorder); suicide attempt; psychosis; depression; factitious disorder; malingering; cognitive disorders, including dementia and delirium; treatment of constipation and hemorrhoids; concealment; attention-seeking behavior; “accidental”; assault; and the consequences of drunken wagers.^1,2 Additionally, abuse should be considered, especially in patients with developmental delay and/or psychiatric illness.

Close to 20% of all traumatic rectal injuries are due to foreign body insertions. In most cases, foreign bodies fail to cause significant anorectal injuries. Complications, however, can result from the process of insertion, removal, or from the contents introduced into the orifice.¹ Any rectal examination should be preceded by an anatomical survey utilizing radiographic modalities to evaluate the integrity and orientation of the object in question. Any sharp object can injure the examining physician if this is not done prior. All examinations should be chaperoned.^2,7 The most obvious and dangerous complication is perforation, and the patient’s care should proceed in the same manner as any other trauma patient. Additionally, resulting sepsis should be managed with the same standards as any other septic patient.⁷

Treatment. The method of object removal is determined by the presence or absence of a surgical abdomen and the need for general anesthesia. The location and shape of the object, however, may not equate with successful retrieval. Objects placed in the sigmoid colon are more than twice as likely to require surgical intervention compared to items placed distally.² Once it is determined that the patient is clinically stable and does not have an acute abdomen, attempts in removing the rectal foreign object can be done in the ED or, if anesthesia is needed, in the OR. Any attempts at transanal removal require optimal patient relaxation, which can be achieved via procedural sedation. The patient should be placed in a lithotomy or left lateral decubitus position to allow palpation of the object in the lower gastrointestinal tract. From here, several methods of removal can be employed. Blunt objects can be grasped and removed by a gloved hand or with a clamp. A Foley catheter can also be passed alongside the object and the balloon inflated above the foreign body to aid in extraction as the Foley is pulled out slowly. Sengstaken-Blakemore tubes, obstetric forceps, and vacuum extractors have also been utilized.⁷

While bedside extraction is advocated by many authors, Cawich et al⁸ recently reported that transanal extraction in the ED failed in 89% of cases. Additionally, these researchers reported that in 63% of the failed extractions, the objects were inadvertently pushed higher into the rectosigmoid region, and therefore recommended early mobilization of the OR team so that exploration under anesthesia can be performed under optimal conditions.⁸

Once the foreign body is successfully removed, follow-up imaging or postextraction endoscopy is warranted. Close observation in the hospital is recommended to facilitate serial abdominal examination.⁷

Urethral Insertions

Sexual exploration, efforts at contraception, transport of illicit drugs, assault or sexual violence, and accidental insertion have all been described as reasons for genitourinary (GU) insertion.¹ The motives, however, mirror those who insert foreign bodies rectally.

Most presentations are due to pain or inability to void. Aggressive treatment should be undertaken because even when the penis appears dark or necrotic, salvage rates have been high. Complications include urinary tract infections, hematuria, urinary retention, urethral tears, abscess, ascending GU infections, and diverticula and fistula formations.^1,3 In women, vaginal insertions can lead to pelvic pain and septic shock.¹ Foreign bodies can also lead to a condition first described in the ancient literature as strangury—the process of slow and painful discharge of urine due to a significant inflammatory component or stricture. The term strangury has been replaced with the more general term bladder spasms.⁹

Treatment. Removal of urethral foreign bodies typically is done in conjunction with a urologist. A cystoscopic procedure is usually successful in removing the foreign body and is an effective method to minimize urethral and bladder injuries. However, more invasive surgical options, including perineal urethrotomy, suprapubic cystostomy, cystolithotomy, and external urethrotomy, have been used in more complicated cases or when the foreign body prevents urethral access of an endoscopic instrument.¹⁰

Patient and Staff Reactions

When patients realize they are unable to remove the inserted object, some present immediately to the ED for evaluation. Interestingly, others may wait up to 2 weeks after insertion before seeking help.² Patients report feelings of being ashamed and report a feeling of being despised, frowned upon, and being talked about during the course of their ED evaluation. As a consequence, these patients may not readily come to the ED or if they do come, may not be open to conversation and hide the true reason of why they came in the first place.^1,4 The amplified paranoia and perceived prejudice may delay diagnosis and lifesaving measures, or worse, lead patients to leave prior to a medical screening examination. Therefore, creating a nonjudgmental environment is essential, even when the presenting story appears to be fabricated.²

Once the patient’s foreign body is removed, and complications are excluded or properly managed, the goal is to understand the motivation behind the insertion, mitigate the consequences of the behavior, and prevent future recurrence. A psychiatric evaluation should be obtained in the ED, or if the patient is admitted, during hospitalization. Psychiatric behavior leading to insertions can be unmasked, treated, and harm-reduction strategies can be taught and instituted.^1,3

Experienced ED staff members are used to the unpredictability of human behavior. However, patients who present with foreign body insertions can elicit a mixture of responses, ranging from awe and incredulousness to anger and frustration. It is not unusual for staff members to not understand or recognize their own reactions. The unique nature of the presentation, along with the astonishing radiographic images, can lead to a breach of privacy and dissemination of the digital photographs by cell phones and into social media sites.¹ Staff members should be encouraged to foster open-mindedness and indifference. Ensuring privacy, professionalism, and empathy can go a long way to helping these patients. Moreover, ED staff members should be educated about countertransference reactions,¹ as these actions are necessary to ensure the singular purpose of optimum patient-staff relationship.

Conclusion

Patients with foreign body insertions challenge the ED staff, as the presenting complaint not only tests the collective technical know-how of the staff, but also their emotional competencies. A nonjudgmental and open-minded approach is crucial, with the tone set during triage. Coordination with surgical specialties should be done early to ensure safe removal and to identify and manage complications. Psychiatric evaluation should be strongly considered prior to disposition in an attempt to prevent future recurrences.

Anorectal and urethral foreign body insertions (polyembolokoilamania) are not infrequent presentations to the ED. The motivations behind these insertions vary, ranging from autoeroticism to reckless behavior. These insertions can lead to major complications and even death. Though ED staff members are used to the unpredictability of human behavior, foreign body insertions bring a mixture of responses from the staff, ranging from awe and incredulousness to anger and frustration. A knowledge and comfort in managing these cases includes a nonjudgmental triage assessment, collective professionalism, and self-awareness of the staff’s reaction.

Case 1

A 58-year-old man presented to the ED for evaluation of a foreign body in his rectum. He admitted to placing a beer bottle in his rectum, but was unable to remove it at home. The staff reported that the patient was previously seen in the ED for removal of a vibrator from his rectum.

Radiographic evaluation in the form of an acute abdominal series was obtained and confirmed a beer bottle in the rectum (Figures 1 and 2).

Case 2

A 55-year-old man presented to the ED after he inserted a pen cap into his urethra to aid in obtaining an erection. A pelvic X-ray was obtained and showed a radiolucent structure in the penis (Figure 3).

The patient was admitted to the hospital and taken to the OR by the consulting urologist. Using a rigid cystoscope and flexible graspers, the pen cap was removed from the proximal urethra under monitored anesthesia control. The procedure went without any complications.

A psychiatrist was consulted, and during the encounter, the patient admitted that his behavior was pathological. He revealed that he was a victim of child abuse and reported he had been having mixed emotions of anxiety, guilt, and embarrassment because of his behavior.

Discussion

Foreign body insertions are seen in patients with a wide variety of backgrounds, ages, and lifestyles. Approximately 80,000 cases of foreign body ingestion are seen annually in children under age 20 years. Young males have a higher predilection of swallowing foreign bodies when compared to young females,¹ and rectal foreign body insertions are seen more commonly in males than in females.² In this age group, intentional foreign body insertion may be an initial manifestation of psychiatric illness.

Rectal Insertions

The earliest published report of a rectal foreign body insertion was in 1919 by Smiley.⁶ The typical age at presentation ranges from 20 to 90 years old, with a mean age of 44 years old.² Household objects such as bottles and glasses are the most commonly seen, but a long list of other items have also been reported in the literature, including toothbrushes, knives, deodorant bottles, food articles, sports equipment, cell phones, flashlights, wooden rods, broomsticks, sex toys, light bulbs, construction tools, nails, ornaments, aerosol canisters, cocaine packets, jewelry, batteries, guitar picks, and many other items.^1,2,7

In nearly half of the reported cases, the reasons for rectal insertion was for sexual arousal/stimulation.^1,7 Other reasons include nonsuicidal injurious behavior (eg, borderline personality disorder); suicide attempt; psychosis; depression; factitious disorder; malingering; cognitive disorders, including dementia and delirium; treatment of constipation and hemorrhoids; concealment; attention-seeking behavior; “accidental”; assault; and the consequences of drunken wagers.^1,2 Additionally, abuse should be considered, especially in patients with developmental delay and/or psychiatric illness.

Close to 20% of all traumatic rectal injuries are due to foreign body insertions. In most cases, foreign bodies fail to cause significant anorectal injuries. Complications, however, can result from the process of insertion, removal, or from the contents introduced into the orifice.¹ Any rectal examination should be preceded by an anatomical survey utilizing radiographic modalities to evaluate the integrity and orientation of the object in question. Any sharp object can injure the examining physician if this is not done prior. All examinations should be chaperoned.^2,7 The most obvious and dangerous complication is perforation, and the patient’s care should proceed in the same manner as any other trauma patient. Additionally, resulting sepsis should be managed with the same standards as any other septic patient.⁷

Treatment. The method of object removal is determined by the presence or absence of a surgical abdomen and the need for general anesthesia. The location and shape of the object, however, may not equate with successful retrieval. Objects placed in the sigmoid colon are more than twice as likely to require surgical intervention compared to items placed distally.² Once it is determined that the patient is clinically stable and does not have an acute abdomen, attempts in removing the rectal foreign object can be done in the ED or, if anesthesia is needed, in the OR. Any attempts at transanal removal require optimal patient relaxation, which can be achieved via procedural sedation. The patient should be placed in a lithotomy or left lateral decubitus position to allow palpation of the object in the lower gastrointestinal tract. From here, several methods of removal can be employed. Blunt objects can be grasped and removed by a gloved hand or with a clamp. A Foley catheter can also be passed alongside the object and the balloon inflated above the foreign body to aid in extraction as the Foley is pulled out slowly. Sengstaken-Blakemore tubes, obstetric forceps, and vacuum extractors have also been utilized.⁷

While bedside extraction is advocated by many authors, Cawich et al⁸ recently reported that transanal extraction in the ED failed in 89% of cases. Additionally, these researchers reported that in 63% of the failed extractions, the objects were inadvertently pushed higher into the rectosigmoid region, and therefore recommended early mobilization of the OR team so that exploration under anesthesia can be performed under optimal conditions.⁸

Once the foreign body is successfully removed, follow-up imaging or postextraction endoscopy is warranted. Close observation in the hospital is recommended to facilitate serial abdominal examination.⁷

Urethral Insertions

Sexual exploration, efforts at contraception, transport of illicit drugs, assault or sexual violence, and accidental insertion have all been described as reasons for genitourinary (GU) insertion.¹ The motives, however, mirror those who insert foreign bodies rectally.

Most presentations are due to pain or inability to void. Aggressive treatment should be undertaken because even when the penis appears dark or necrotic, salvage rates have been high. Complications include urinary tract infections, hematuria, urinary retention, urethral tears, abscess, ascending GU infections, and diverticula and fistula formations.^1,3 In women, vaginal insertions can lead to pelvic pain and septic shock.¹ Foreign bodies can also lead to a condition first described in the ancient literature as strangury—the process of slow and painful discharge of urine due to a significant inflammatory component or stricture. The term strangury has been replaced with the more general term bladder spasms.⁹

Treatment. Removal of urethral foreign bodies typically is done in conjunction with a urologist. A cystoscopic procedure is usually successful in removing the foreign body and is an effective method to minimize urethral and bladder injuries. However, more invasive surgical options, including perineal urethrotomy, suprapubic cystostomy, cystolithotomy, and external urethrotomy, have been used in more complicated cases or when the foreign body prevents urethral access of an endoscopic instrument.¹⁰

Patient and Staff Reactions

When patients realize they are unable to remove the inserted object, some present immediately to the ED for evaluation. Interestingly, others may wait up to 2 weeks after insertion before seeking help.² Patients report feelings of being ashamed and report a feeling of being despised, frowned upon, and being talked about during the course of their ED evaluation. As a consequence, these patients may not readily come to the ED or if they do come, may not be open to conversation and hide the true reason of why they came in the first place.^1,4 The amplified paranoia and perceived prejudice may delay diagnosis and lifesaving measures, or worse, lead patients to leave prior to a medical screening examination. Therefore, creating a nonjudgmental environment is essential, even when the presenting story appears to be fabricated.²

Once the patient’s foreign body is removed, and complications are excluded or properly managed, the goal is to understand the motivation behind the insertion, mitigate the consequences of the behavior, and prevent future recurrence. A psychiatric evaluation should be obtained in the ED, or if the patient is admitted, during hospitalization. Psychiatric behavior leading to insertions can be unmasked, treated, and harm-reduction strategies can be taught and instituted.^1,3

Experienced ED staff members are used to the unpredictability of human behavior. However, patients who present with foreign body insertions can elicit a mixture of responses, ranging from awe and incredulousness to anger and frustration. It is not unusual for staff members to not understand or recognize their own reactions. The unique nature of the presentation, along with the astonishing radiographic images, can lead to a breach of privacy and dissemination of the digital photographs by cell phones and into social media sites.¹ Staff members should be encouraged to foster open-mindedness and indifference. Ensuring privacy, professionalism, and empathy can go a long way to helping these patients. Moreover, ED staff members should be educated about countertransference reactions,¹ as these actions are necessary to ensure the singular purpose of optimum patient-staff relationship.

Conclusion

Patients with foreign body insertions challenge the ED staff, as the presenting complaint not only tests the collective technical know-how of the staff, but also their emotional competencies. A nonjudgmental and open-minded approach is crucial, with the tone set during triage. Coordination with surgical specialties should be done early to ensure safe removal and to identify and manage complications. Psychiatric evaluation should be strongly considered prior to disposition in an attempt to prevent future recurrences.

Anorectal and urethral foreign body insertions (polyembolokoilamania) are not infrequent presentations to the ED. The motivations behind these insertions vary, ranging from autoeroticism to reckless behavior. These insertions can lead to major complications and even death. Though ED staff members are used to the unpredictability of human behavior, foreign body insertions bring a mixture of responses from the staff, ranging from awe and incredulousness to anger and frustration. A knowledge and comfort in managing these cases includes a nonjudgmental triage assessment, collective professionalism, and self-awareness of the staff’s reaction.

Case 1

A 58-year-old man presented to the ED for evaluation of a foreign body in his rectum. He admitted to placing a beer bottle in his rectum, but was unable to remove it at home. The staff reported that the patient was previously seen in the ED for removal of a vibrator from his rectum.

Radiographic evaluation in the form of an acute abdominal series was obtained and confirmed a beer bottle in the rectum (Figures 1 and 2).

Case 2

A 55-year-old man presented to the ED after he inserted a pen cap into his urethra to aid in obtaining an erection. A pelvic X-ray was obtained and showed a radiolucent structure in the penis (Figure 3).

The patient was admitted to the hospital and taken to the OR by the consulting urologist. Using a rigid cystoscope and flexible graspers, the pen cap was removed from the proximal urethra under monitored anesthesia control. The procedure went without any complications.

A psychiatrist was consulted, and during the encounter, the patient admitted that his behavior was pathological. He revealed that he was a victim of child abuse and reported he had been having mixed emotions of anxiety, guilt, and embarrassment because of his behavior.

Discussion

Foreign body insertions are seen in patients with a wide variety of backgrounds, ages, and lifestyles. Approximately 80,000 cases of foreign body ingestion are seen annually in children under age 20 years. Young males have a higher predilection of swallowing foreign bodies when compared to young females,¹ and rectal foreign body insertions are seen more commonly in males than in females.² In this age group, intentional foreign body insertion may be an initial manifestation of psychiatric illness.

Rectal Insertions

The earliest published report of a rectal foreign body insertion was in 1919 by Smiley.⁶ The typical age at presentation ranges from 20 to 90 years old, with a mean age of 44 years old.² Household objects such as bottles and glasses are the most commonly seen, but a long list of other items have also been reported in the literature, including toothbrushes, knives, deodorant bottles, food articles, sports equipment, cell phones, flashlights, wooden rods, broomsticks, sex toys, light bulbs, construction tools, nails, ornaments, aerosol canisters, cocaine packets, jewelry, batteries, guitar picks, and many other items.^1,2,7

In nearly half of the reported cases, the reasons for rectal insertion was for sexual arousal/stimulation.^1,7 Other reasons include nonsuicidal injurious behavior (eg, borderline personality disorder); suicide attempt; psychosis; depression; factitious disorder; malingering; cognitive disorders, including dementia and delirium; treatment of constipation and hemorrhoids; concealment; attention-seeking behavior; “accidental”; assault; and the consequences of drunken wagers.^1,2 Additionally, abuse should be considered, especially in patients with developmental delay and/or psychiatric illness.

Close to 20% of all traumatic rectal injuries are due to foreign body insertions. In most cases, foreign bodies fail to cause significant anorectal injuries. Complications, however, can result from the process of insertion, removal, or from the contents introduced into the orifice.¹ Any rectal examination should be preceded by an anatomical survey utilizing radiographic modalities to evaluate the integrity and orientation of the object in question. Any sharp object can injure the examining physician if this is not done prior. All examinations should be chaperoned.^2,7 The most obvious and dangerous complication is perforation, and the patient’s care should proceed in the same manner as any other trauma patient. Additionally, resulting sepsis should be managed with the same standards as any other septic patient.⁷

Treatment. The method of object removal is determined by the presence or absence of a surgical abdomen and the need for general anesthesia. The location and shape of the object, however, may not equate with successful retrieval. Objects placed in the sigmoid colon are more than twice as likely to require surgical intervention compared to items placed distally.² Once it is determined that the patient is clinically stable and does not have an acute abdomen, attempts in removing the rectal foreign object can be done in the ED or, if anesthesia is needed, in the OR. Any attempts at transanal removal require optimal patient relaxation, which can be achieved via procedural sedation. The patient should be placed in a lithotomy or left lateral decubitus position to allow palpation of the object in the lower gastrointestinal tract. From here, several methods of removal can be employed. Blunt objects can be grasped and removed by a gloved hand or with a clamp. A Foley catheter can also be passed alongside the object and the balloon inflated above the foreign body to aid in extraction as the Foley is pulled out slowly. Sengstaken-Blakemore tubes, obstetric forceps, and vacuum extractors have also been utilized.⁷

While bedside extraction is advocated by many authors, Cawich et al⁸ recently reported that transanal extraction in the ED failed in 89% of cases. Additionally, these researchers reported that in 63% of the failed extractions, the objects were inadvertently pushed higher into the rectosigmoid region, and therefore recommended early mobilization of the OR team so that exploration under anesthesia can be performed under optimal conditions.⁸

Once the foreign body is successfully removed, follow-up imaging or postextraction endoscopy is warranted. Close observation in the hospital is recommended to facilitate serial abdominal examination.⁷

Urethral Insertions

Sexual exploration, efforts at contraception, transport of illicit drugs, assault or sexual violence, and accidental insertion have all been described as reasons for genitourinary (GU) insertion.¹ The motives, however, mirror those who insert foreign bodies rectally.

Most presentations are due to pain or inability to void. Aggressive treatment should be undertaken because even when the penis appears dark or necrotic, salvage rates have been high. Complications include urinary tract infections, hematuria, urinary retention, urethral tears, abscess, ascending GU infections, and diverticula and fistula formations.^1,3 In women, vaginal insertions can lead to pelvic pain and septic shock.¹ Foreign bodies can also lead to a condition first described in the ancient literature as strangury—the process of slow and painful discharge of urine due to a significant inflammatory component or stricture. The term strangury has been replaced with the more general term bladder spasms.⁹

Treatment. Removal of urethral foreign bodies typically is done in conjunction with a urologist. A cystoscopic procedure is usually successful in removing the foreign body and is an effective method to minimize urethral and bladder injuries. However, more invasive surgical options, including perineal urethrotomy, suprapubic cystostomy, cystolithotomy, and external urethrotomy, have been used in more complicated cases or when the foreign body prevents urethral access of an endoscopic instrument.¹⁰

Patient and Staff Reactions

When patients realize they are unable to remove the inserted object, some present immediately to the ED for evaluation. Interestingly, others may wait up to 2 weeks after insertion before seeking help.² Patients report feelings of being ashamed and report a feeling of being despised, frowned upon, and being talked about during the course of their ED evaluation. As a consequence, these patients may not readily come to the ED or if they do come, may not be open to conversation and hide the true reason of why they came in the first place.^1,4 The amplified paranoia and perceived prejudice may delay diagnosis and lifesaving measures, or worse, lead patients to leave prior to a medical screening examination. Therefore, creating a nonjudgmental environment is essential, even when the presenting story appears to be fabricated.²

Once the patient’s foreign body is removed, and complications are excluded or properly managed, the goal is to understand the motivation behind the insertion, mitigate the consequences of the behavior, and prevent future recurrence. A psychiatric evaluation should be obtained in the ED, or if the patient is admitted, during hospitalization. Psychiatric behavior leading to insertions can be unmasked, treated, and harm-reduction strategies can be taught and instituted.^1,3

Experienced ED staff members are used to the unpredictability of human behavior. However, patients who present with foreign body insertions can elicit a mixture of responses, ranging from awe and incredulousness to anger and frustration. It is not unusual for staff members to not understand or recognize their own reactions. The unique nature of the presentation, along with the astonishing radiographic images, can lead to a breach of privacy and dissemination of the digital photographs by cell phones and into social media sites.¹ Staff members should be encouraged to foster open-mindedness and indifference. Ensuring privacy, professionalism, and empathy can go a long way to helping these patients. Moreover, ED staff members should be educated about countertransference reactions,¹ as these actions are necessary to ensure the singular purpose of optimum patient-staff relationship.

Conclusion

Patients with foreign body insertions challenge the ED staff, as the presenting complaint not only tests the collective technical know-how of the staff, but also their emotional competencies. A nonjudgmental and open-minded approach is crucial, with the tone set during triage. Coordination with surgical specialties should be done early to ensure safe removal and to identify and manage complications. Psychiatric evaluation should be strongly considered prior to disposition in an attempt to prevent future recurrences.

A 69-year-old woman with hypertension, diabetes mellitus, and chronic kidney disease presented with a 1-month history of worsening episodic dyspnea, lower-extremity edema, and dizziness. Two months earlier, she had been diagnosed with poorly differentiated pelvic adnexal sarcoma associated with a mature teratoma of the left ovary, and she had undergone bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy.

Examination revealed tachypnea (23 breaths per minute) and bilateral pitting pedal edema. The neck veins were distended. There was no hepatomegaly. Results of laboratory testing were unremarkable.

EVALUATING A CARDIAC MASS

Thrombus, tumor, or vegetation?

If an intracardiac mass is discovered, we need to determine what it is.

Thrombosis is more likely if contrast echocardiography shows the mass has no stalk (thrombi almost never have a stalk), the atrial chamber is enlarged, cardiac output is low, there is stasis, the mass is avascular, and it responds to thrombolytic therapy. A giant organized thrombus can clinically mimic a tumor if it is immobile, is located close to the wall, and responds poorly to thrombolysis. A wall-motion abnormality adjacent to the mass, global hypokinesis, or a concomitant autoimmune condition such as lupus erythematosus or antiphospholipid antibody syndrome may also favor thrombosis.

Tumors in the heart are uncommon. The prevalence of primary cardiac tumors has been reported as 0.01% to 0.1% in autopsy studies. Metastases to the pericardium, myocardium, coronary arteries, or great vessels have been found at autopsy in 0.7% to 3.5% of the general population and in 9.1% of patients with known malignancy.¹

Vegetations from infective endocarditis should also be considered early in the evaluation of an intracardiac mass. They can result from bacterial, fungal, or parasitic infection. Vegetations are generally irregular in appearance, mobile, and attached to a valve. Left-sided valves are generally involved, and a larger mass may indicate fungal origin. Abscess from tuberculosis may need to be considered in the appropriate setting. Whenever feasible, tissue diagnosis is desirable.

Occasionally, there may be an inflammatory component to masses detected in the setting of autoimmune disease.

If echocardiography cannot clearly distinguish whether the mass is a tumor or a thrombus, MRI with gadolinium contrast is useful. MRI is superior to CT in depicting anatomic details and does not involve radiation.

Cardiac CT is increasingly used when other imaging findings are equivocal or to study a calcified mass. CT with contrast carries a small risk of contrast-induced nephropathy and has lower soft-tissue and temporal resolution. CT without contrast can detect the mass and reveal calcifications within the mass, but contrast is needed to assess the vascularity of the tumor. New-generation CT with electrocardiographic gating nearly matches MRI imaging, and CT is preferred for patients with contraindications to MRI.

CT provides additional information on the global assessment of the chest, lung and vascular structures.² Cardiac CT and MRI help in precise anatomic delineation, characterization, and preoperative planning of treatment of a large cardiac mass.

TYPES OF CARDIAC TUMORS

Metastases account for most cardiac tumors and are often from primary cancers of the lung, breast, skin, thyroid, and kidney.

Primary cardiac tumors are most often myxomas, which are benign and generally found in the atrial chamber, solitary, with a stalk attached to the area of the fossa ovalis. Other primary cardiac tumors include sarcomas, angiosarcomas, rhabdomyosarcomas, papillary fibroelastomas, lipomas, hemangiomas, mesotheliomas, and rhabdomyomas.

TREATMENT OF CARDIAC TUMORS

For primary and secondary cardiac tumors, complete resection should be considered, provided there is no other organ involvement.³ For suspected lymphomas, image-guided biopsy should be performed before treatment.

For uncertain and diagnostically challenging cases, guided biopsy of the lesions using intracardiac echocardiography or transesophageal echocardiography has been reported to be helpful.⁴

Most often, the workup and management of cardiac masses calls for a team involving an internist, cardiologist, cardiothoracic surgeon, and vascular medicine specialist. Depending on the nature of the mass, the team may also include an oncologist, radiotherapist, and infectious disease specialist.

Because our patient had significant kidney disease, CT was done without contrast. However, it was not able to clearly delineate the mass in the right ventricle. Cardiac MRI was not performed. Biopsy with transesophageal or intracardiac echocardiographic guidance was not an option, as the patient’s condition was poor.

TAKE-HOME POINTS

The differential diagnosis of an intracardiac mass includes thrombus, benign or malignant tumors, and masses of infectious or inflammatory origin. While noninvasive imaging tests provide clues that can help narrow the differential diagnosis, tissue biopsy with histologic study is necessary to confirm the diagnosis. A team approach is paramount in managing cardiac masses.

A 69-year-old woman with hypertension, diabetes mellitus, and chronic kidney disease presented with a 1-month history of worsening episodic dyspnea, lower-extremity edema, and dizziness. Two months earlier, she had been diagnosed with poorly differentiated pelvic adnexal sarcoma associated with a mature teratoma of the left ovary, and she had undergone bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy.

Examination revealed tachypnea (23 breaths per minute) and bilateral pitting pedal edema. The neck veins were distended. There was no hepatomegaly. Results of laboratory testing were unremarkable.

EVALUATING A CARDIAC MASS

Thrombus, tumor, or vegetation?

If an intracardiac mass is discovered, we need to determine what it is.

Thrombosis is more likely if contrast echocardiography shows the mass has no stalk (thrombi almost never have a stalk), the atrial chamber is enlarged, cardiac output is low, there is stasis, the mass is avascular, and it responds to thrombolytic therapy. A giant organized thrombus can clinically mimic a tumor if it is immobile, is located close to the wall, and responds poorly to thrombolysis. A wall-motion abnormality adjacent to the mass, global hypokinesis, or a concomitant autoimmune condition such as lupus erythematosus or antiphospholipid antibody syndrome may also favor thrombosis.

Tumors in the heart are uncommon. The prevalence of primary cardiac tumors has been reported as 0.01% to 0.1% in autopsy studies. Metastases to the pericardium, myocardium, coronary arteries, or great vessels have been found at autopsy in 0.7% to 3.5% of the general population and in 9.1% of patients with known malignancy.¹

Vegetations from infective endocarditis should also be considered early in the evaluation of an intracardiac mass. They can result from bacterial, fungal, or parasitic infection. Vegetations are generally irregular in appearance, mobile, and attached to a valve. Left-sided valves are generally involved, and a larger mass may indicate fungal origin. Abscess from tuberculosis may need to be considered in the appropriate setting. Whenever feasible, tissue diagnosis is desirable.

Occasionally, there may be an inflammatory component to masses detected in the setting of autoimmune disease.

If echocardiography cannot clearly distinguish whether the mass is a tumor or a thrombus, MRI with gadolinium contrast is useful. MRI is superior to CT in depicting anatomic details and does not involve radiation.

Cardiac CT is increasingly used when other imaging findings are equivocal or to study a calcified mass. CT with contrast carries a small risk of contrast-induced nephropathy and has lower soft-tissue and temporal resolution. CT without contrast can detect the mass and reveal calcifications within the mass, but contrast is needed to assess the vascularity of the tumor. New-generation CT with electrocardiographic gating nearly matches MRI imaging, and CT is preferred for patients with contraindications to MRI.

CT provides additional information on the global assessment of the chest, lung and vascular structures.² Cardiac CT and MRI help in precise anatomic delineation, characterization, and preoperative planning of treatment of a large cardiac mass.

TYPES OF CARDIAC TUMORS

Metastases account for most cardiac tumors and are often from primary cancers of the lung, breast, skin, thyroid, and kidney.

Primary cardiac tumors are most often myxomas, which are benign and generally found in the atrial chamber, solitary, with a stalk attached to the area of the fossa ovalis. Other primary cardiac tumors include sarcomas, angiosarcomas, rhabdomyosarcomas, papillary fibroelastomas, lipomas, hemangiomas, mesotheliomas, and rhabdomyomas.

TREATMENT OF CARDIAC TUMORS

For primary and secondary cardiac tumors, complete resection should be considered, provided there is no other organ involvement.³ For suspected lymphomas, image-guided biopsy should be performed before treatment.

For uncertain and diagnostically challenging cases, guided biopsy of the lesions using intracardiac echocardiography or transesophageal echocardiography has been reported to be helpful.⁴

Most often, the workup and management of cardiac masses calls for a team involving an internist, cardiologist, cardiothoracic surgeon, and vascular medicine specialist. Depending on the nature of the mass, the team may also include an oncologist, radiotherapist, and infectious disease specialist.

Because our patient had significant kidney disease, CT was done without contrast. However, it was not able to clearly delineate the mass in the right ventricle. Cardiac MRI was not performed. Biopsy with transesophageal or intracardiac echocardiographic guidance was not an option, as the patient’s condition was poor.

TAKE-HOME POINTS

The differential diagnosis of an intracardiac mass includes thrombus, benign or malignant tumors, and masses of infectious or inflammatory origin. While noninvasive imaging tests provide clues that can help narrow the differential diagnosis, tissue biopsy with histologic study is necessary to confirm the diagnosis. A team approach is paramount in managing cardiac masses.

A 69-year-old woman with hypertension, diabetes mellitus, and chronic kidney disease presented with a 1-month history of worsening episodic dyspnea, lower-extremity edema, and dizziness. Two months earlier, she had been diagnosed with poorly differentiated pelvic adnexal sarcoma associated with a mature teratoma of the left ovary, and she had undergone bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy.

Examination revealed tachypnea (23 breaths per minute) and bilateral pitting pedal edema. The neck veins were distended. There was no hepatomegaly. Results of laboratory testing were unremarkable.

EVALUATING A CARDIAC MASS

Thrombus, tumor, or vegetation?

If an intracardiac mass is discovered, we need to determine what it is.

Thrombosis is more likely if contrast echocardiography shows the mass has no stalk (thrombi almost never have a stalk), the atrial chamber is enlarged, cardiac output is low, there is stasis, the mass is avascular, and it responds to thrombolytic therapy. A giant organized thrombus can clinically mimic a tumor if it is immobile, is located close to the wall, and responds poorly to thrombolysis. A wall-motion abnormality adjacent to the mass, global hypokinesis, or a concomitant autoimmune condition such as lupus erythematosus or antiphospholipid antibody syndrome may also favor thrombosis.

Tumors in the heart are uncommon. The prevalence of primary cardiac tumors has been reported as 0.01% to 0.1% in autopsy studies. Metastases to the pericardium, myocardium, coronary arteries, or great vessels have been found at autopsy in 0.7% to 3.5% of the general population and in 9.1% of patients with known malignancy.¹

Vegetations from infective endocarditis should also be considered early in the evaluation of an intracardiac mass. They can result from bacterial, fungal, or parasitic infection. Vegetations are generally irregular in appearance, mobile, and attached to a valve. Left-sided valves are generally involved, and a larger mass may indicate fungal origin. Abscess from tuberculosis may need to be considered in the appropriate setting. Whenever feasible, tissue diagnosis is desirable.

Occasionally, there may be an inflammatory component to masses detected in the setting of autoimmune disease.

If echocardiography cannot clearly distinguish whether the mass is a tumor or a thrombus, MRI with gadolinium contrast is useful. MRI is superior to CT in depicting anatomic details and does not involve radiation.

Cardiac CT is increasingly used when other imaging findings are equivocal or to study a calcified mass. CT with contrast carries a small risk of contrast-induced nephropathy and has lower soft-tissue and temporal resolution. CT without contrast can detect the mass and reveal calcifications within the mass, but contrast is needed to assess the vascularity of the tumor. New-generation CT with electrocardiographic gating nearly matches MRI imaging, and CT is preferred for patients with contraindications to MRI.

CT provides additional information on the global assessment of the chest, lung and vascular structures.² Cardiac CT and MRI help in precise anatomic delineation, characterization, and preoperative planning of treatment of a large cardiac mass.

TYPES OF CARDIAC TUMORS

Metastases account for most cardiac tumors and are often from primary cancers of the lung, breast, skin, thyroid, and kidney.

Primary cardiac tumors are most often myxomas, which are benign and generally found in the atrial chamber, solitary, with a stalk attached to the area of the fossa ovalis. Other primary cardiac tumors include sarcomas, angiosarcomas, rhabdomyosarcomas, papillary fibroelastomas, lipomas, hemangiomas, mesotheliomas, and rhabdomyomas.

TREATMENT OF CARDIAC TUMORS

For primary and secondary cardiac tumors, complete resection should be considered, provided there is no other organ involvement.³ For suspected lymphomas, image-guided biopsy should be performed before treatment.

For uncertain and diagnostically challenging cases, guided biopsy of the lesions using intracardiac echocardiography or transesophageal echocardiography has been reported to be helpful.⁴

Most often, the workup and management of cardiac masses calls for a team involving an internist, cardiologist, cardiothoracic surgeon, and vascular medicine specialist. Depending on the nature of the mass, the team may also include an oncologist, radiotherapist, and infectious disease specialist.

Because our patient had significant kidney disease, CT was done without contrast. However, it was not able to clearly delineate the mass in the right ventricle. Cardiac MRI was not performed. Biopsy with transesophageal or intracardiac echocardiographic guidance was not an option, as the patient’s condition was poor.

TAKE-HOME POINTS

The differential diagnosis of an intracardiac mass includes thrombus, benign or malignant tumors, and masses of infectious or inflammatory origin. While noninvasive imaging tests provide clues that can help narrow the differential diagnosis, tissue biopsy with histologic study is necessary to confirm the diagnosis. A team approach is paramount in managing cardiac masses.

Each year, millions of women undergo mammography in the hope of decreasing their risk of dying of breast cancer. The effectiveness of screening mammography, however, continues to be debated.

While most randomized controlled trials have demonstrated significantly lower mortality rates in women who undergo screening, not all trials have. Most experts agree that screening mammography programs decrease breast cancer mortality rates by 12% to 33%.^1,2 But some point out that although mammography programs clearly detect more cases of breast cancer, some proportion of this detection may include “overdiagnosis” of cancers that would not have caused morbidity or mortality, including ductal carcinoma in situ. Also, although deaths from breast cancer have decreased in the United States, at least some of the decrease may be due to more effective treatment rather than early detection.

Moreover, screening has well-documented harms. False-positive results cause alarm and expose women to needless follow-up imaging and biopsies, with their attendant inconvenience, discomfort, risks, and costs. Conversely, false-negative results (especially common in women with dense breasts) lead to missed diagnosis and a false sense of security.

How could programs and technology be improved to make screening more beneficial, both for patients and for society as a whole? A major improvement would be if mammography could be made more sensitive and specific for detecting invasive cancers, with fewer false-positive results. Lower cost and less frequent screening would also be major improvements.

Digital breast tomosynthesis (DBT), also known as 3-dimensional (3D) mammography, may be a way to improve the value of breast cancer screening programs. In 2011, the US Food and Drug Administration (FDA) approved DBT for all mammographic indications, including screening.

WHAT IS TOMOSYNTHESIS?

In DBT, the x-ray source is rotated in an arc around the patient’s breast (Figure 1), generating a 3D image.³ DBT is now routinely built into newer-generation mammography units. The 3D projections of DBT are obtained during the same breast compression required for standard 2D digital mammography. Thus, DBT requires minimal additional time on the part of the patient and the technologist.⁴

The 3D images are processed and sent to a viewing station, where a radiologist can interpret them next to 2D images. The radiologist has the ability to scroll through the DBT projections slice by slice, as in other cross-sectional imaging examinations. However, given the larger number of images compared with digital mammography, DBT requires more time for interpretation, interrupting the workflow. A population-based observational study suggested that combined digital mammography and DBT screening examinations take twice as long to interpret.⁵

The main advantage of DBT is that it can mitigate the problem of overlapping breast tissue on standard digital projections. These areas of focal asymmetry may represent suspicious masses—or merely overlapping breast parenchyma. When areas of focal asymmetry are found on 2D digital mammography without DBT, patients need to come back for further diagnostic imaging to resolve the finding.⁶ In addition, especially in women with dense breasts, areas of overlapping tissue can have a masking effect, obscuring small breast cancers.⁷

Images courtesy of Diana L. Lam, MD, University of Washington, Seattle.

For breast cancer screening, DBT is read in conjunction with standard digital mammography. By allowing examination of the breast parenchyma in thin slices, DBT decreases the interpretive issue of overlapping breast parenchyma and the masking effect, potentially leading to fewer false-positive results and higher rates of cancer detection (Figure 2).

EFFECTIVENESS OF TOMOSYNTHESIS

There is limited evidence at this time to support the addition of DBT to digital mammography for primary breast cancer screening, with no published randomized trials that assessed outcomes. However, 2 population-based trials in Europe have prospectively assessed DBT plus digital mammography as a primary screening strategy: the Screening With Tomosynthesis or Standard Mammography (STORM) trial⁸ and the Oslo tomosynthesis screening trial.⁵ Only the STORM trial reported first-year interval cancer rates, from which the sensitivity and specificity of DBT plus 2D digital mammography could be calculated and compared with those of 2D digital mammography alone.⁸

In April 2013, the Oslo tomosynthesis screening trial published interim results of its prospective cohort study of 12,631 Norwegian women ages 50 to 69.⁵ Women were invited to participate based on the availability of technical staff and imaging systems at the time of screening, and all participants underwent digital mammography and DBT. Images were read independently by 4 radiologists using a double-reader protocol.

The interim results suggest that adding DBT to digital mammography increased cancer detection rates by 31% and decreased the false-positive rate by 13% compared with 2D digital mammography alone (Table 1). However, the double-reader protocol in this study differs from typical single-reader protocols in the United States, limiting the applicability of the findings.

The STORM trial: Low sensitivity

The STORM trial is a prospective cohort study that included 7,292 women without symptoms, at average risk, age 48 and older, who participated in national breast cancer screening services in northern Italy. Each participant underwent digital mammography and DBT. The examinations were read sequentially (digital mammography first, then DBT plus digital mammography) either by a single radiologist, as is most common in the United States, or by 2 radiologists, as is standard in Europe.

Using the single-reader strategy, adding DBT significantly increased cancer detection rates and reduced the total recall rate (Table 1). Sensitivity was 85% vs 54%, and specificity was 97% vs 96%.^8,9

Of note, the sensitivity of 54% for digital mammography in the STORM trial is substantially lower than the sensitivity of digital mammography reported in the United States.¹⁰

Friedewald et al confirmed Oslo and STORM

To date, the largest US study of DBT plus digital mammography for breast cancer screening was a multicenter retrospective cohort study by Friedewald et al in 2014.¹¹ This study compared cancer detection and recall rates before and after the implementation of DBT at 13 breast centers and evaluated a total of 454,850 examinations (173,663 with DBT plus digital mammography and 281,187 with digital mammography only).

Overall, the recall rate decreased significantly after DBT was adopted and the cancer detection rate increased, findings consistent with those of the STORM and Oslo trials (Table 1). Adding DBT detected invasive cancers at a higher rate than 2D digital mammography alone (4.1/1000 vs 2.9/1,000), while there was no significant difference in ductal carcinoma in situ detection rates. This suggests that the additional cancers detected by DBT may be more clinically important. Nevertheless, the number of biopsies with negative results also increased, suggesting that adding DBT may pose potential harms.

In 2016, Rafferty et al¹² published an additional analysis of the data from Friedewald et al, concluding that adding DBT to 2D digital mammography increased the cancer detection rate more in women with heterogeneously dense breasts than in those with either nondense breasts or extremely dense breasts.¹² The reduction in recall rate was also greatest in the heterogeneously dense subgroup.

Insufficient evidence to recommend

Most other cohort studies comparing DBT and digital mammography have had findings similar to those of the European prospective studies and the large US retrospective cohort study, with the addition of DBT to mammography reducing recall rates and increasing cancer detection rates.¹³ However, many of these studies were subject to potential selection bias and did not provide information on the cancer risk of the participants. In addition, no studies have assessed clinical outcomes such as breast cancer stage at diagnosis or interval cancers, let alone breast cancer mortality.

Rigorous studies need to be done in the United States, using the standard single-reader protocol most often used in this country, to ascertain the clinical outcomes of DBT plus digital mammography for breast cancer screening for women at average risk. A 2016 review cited a dearth of high-quality US studies assessing the role of DBT in primary breast cancer.¹³

The US Preventive Services Task Force, in its 2016 guidelines for breast cancer screening, concluded that there was insufficient evidence to assess the harms and benefits of DBT as a method of breast cancer screening, including adjunctive screening in women with dense breasts.¹

Similarly, the American College of Physicians has advised against screening average-risk women for breast cancer using DBT.¹⁴

APPROVAL, DISSEMINATION, COSTS, AND CHOICE FOR PATIENTS

Even with early promising data suggesting that DBT can increase cancer detection rates and decrease false-positive results when added to routine screening mammography, the rapid diffusion of DBT into clinical practice is outpacing evidence of its effectiveness.⁴ This adoption was spurred in January 2015 when the Centers for Medicare and Medicaid Services added a Current Procedural Terminology code for DBT, allowing for additional reimbursement for it for all mammography indications.¹⁵ Still, the use of DBT in community settings is inconsistent, given the significant up-front costs associated with equipment purchases and variable reimbursement by private insurers who consider the technology experimental.

For the US healthcare system as a whole, it is uncertain whether the purported benefits of DBT will outweigh the additional costs associated with its use. The average reimbursement for a routine digital mammography examination is $135; adding DBT adds an average of $56 to the cost.¹⁵

Using an established, discrete-event breast cancer simulation model, a team of investigators evaluated the cost-effectiveness of combined biennial digital mammography and DBT screening compared with biennial digital mammography screening alone in US women with dense breasts.¹⁶ They found that biennial combined screening is likely to be cost-effective in US women with dense breasts. They also found that for every 2,000 women screened from age 50 to age 74, adding DBT would prevent 1 breast cancer death and 810 false-positive screening examinations.¹⁶

In addition, some have expressed concern that adding DBT to standard digital mammography increases radiation exposure. In fact, the radiation dose with DBT is similar to that with standard 2D digital mammography. Thus, when acquired together, combined digital mammography and DBT screening leads to twice the radiation dose compared with digital mammography alone.¹⁷ Nevertheless, this increased dose remains well below the FDA limits for a screening examination. In addition, the FDA has approved software that allows reconstruction of 2D synthetic views from the 3D data set, which will eventually bring radiation dose levels down to levels comparable to those of conventional digital mammography.¹⁷

Given that DBT is built into newer mammography units and is available as an add-on feature for existing units, its use is likely to increase even faster than digital mammography did when it replaced screen-film mammography in the previous decade.⁴ Its adoption by screening facilities, however, remains variable, and patients wishing to obtain combined DBT and digital mammography screening may have to travel to a different facility from their usual place of screening.¹⁸

Moreover, not all insurance companies cover DBT, resulting in additional out-of-pocket costs to the patient. It is currently unclear how individual facilities are offering DBT services, including how patients are selected for additional DBT and if they are offered the choice to add or forego DBT screening in combination with standard digital mammography.

SUMMARY: AN EMERGING TECHNOLOGY

DBT is an emerging imaging technology that allows the radiologist to view breast images in slices, as in computed tomography. DBT images can be obtained using the same breast compression that women already undergo for 2D digital mammography for breast cancer screening.

At this time, adding DBT to digital mammography screening nearly doubles the radiation exposure to the patient. However, new software is available that allows creation of synthetic 2D views from the 3D data set, resulting in radiation exposure that is similar to conventional digital mammography.

Although there are no published randomized controlled trials assessing the benefit of DBT over 2D digital mammography for breast cancer screening, prospective observational studies suggest that DBT may reduce false-positive recall rates and increase cancer detection rates when used in population-based screening programs. Assuming that additional breast cancer detection contributes to improved clinical outcomes, women with dense breasts may benefit more than women without dense breasts.

No national organizations currently recommend DBT for primary breast cancer screening. Ideally, future studies would determine whether DBT screening reduces breast cancer mortality. Since this research may not be feasible, surrogate clinical outcomes, such as a decrease in interval breast cancer rates and impact on stage at time of diagnosis, would allow us to more confidently recommend this new technology.

Each year, millions of women undergo mammography in the hope of decreasing their risk of dying of breast cancer. The effectiveness of screening mammography, however, continues to be debated.

While most randomized controlled trials have demonstrated significantly lower mortality rates in women who undergo screening, not all trials have. Most experts agree that screening mammography programs decrease breast cancer mortality rates by 12% to 33%.^1,2 But some point out that although mammography programs clearly detect more cases of breast cancer, some proportion of this detection may include “overdiagnosis” of cancers that would not have caused morbidity or mortality, including ductal carcinoma in situ. Also, although deaths from breast cancer have decreased in the United States, at least some of the decrease may be due to more effective treatment rather than early detection.

Moreover, screening has well-documented harms. False-positive results cause alarm and expose women to needless follow-up imaging and biopsies, with their attendant inconvenience, discomfort, risks, and costs. Conversely, false-negative results (especially common in women with dense breasts) lead to missed diagnosis and a false sense of security.

How could programs and technology be improved to make screening more beneficial, both for patients and for society as a whole? A major improvement would be if mammography could be made more sensitive and specific for detecting invasive cancers, with fewer false-positive results. Lower cost and less frequent screening would also be major improvements.

Digital breast tomosynthesis (DBT), also known as 3-dimensional (3D) mammography, may be a way to improve the value of breast cancer screening programs. In 2011, the US Food and Drug Administration (FDA) approved DBT for all mammographic indications, including screening.

WHAT IS TOMOSYNTHESIS?

In DBT, the x-ray source is rotated in an arc around the patient’s breast (Figure 1), generating a 3D image.³ DBT is now routinely built into newer-generation mammography units. The 3D projections of DBT are obtained during the same breast compression required for standard 2D digital mammography. Thus, DBT requires minimal additional time on the part of the patient and the technologist.⁴

The 3D images are processed and sent to a viewing station, where a radiologist can interpret them next to 2D images. The radiologist has the ability to scroll through the DBT projections slice by slice, as in other cross-sectional imaging examinations. However, given the larger number of images compared with digital mammography, DBT requires more time for interpretation, interrupting the workflow. A population-based observational study suggested that combined digital mammography and DBT screening examinations take twice as long to interpret.⁵

The main advantage of DBT is that it can mitigate the problem of overlapping breast tissue on standard digital projections. These areas of focal asymmetry may represent suspicious masses—or merely overlapping breast parenchyma. When areas of focal asymmetry are found on 2D digital mammography without DBT, patients need to come back for further diagnostic imaging to resolve the finding.⁶ In addition, especially in women with dense breasts, areas of overlapping tissue can have a masking effect, obscuring small breast cancers.⁷

Images courtesy of Diana L. Lam, MD, University of Washington, Seattle.

For breast cancer screening, DBT is read in conjunction with standard digital mammography. By allowing examination of the breast parenchyma in thin slices, DBT decreases the interpretive issue of overlapping breast parenchyma and the masking effect, potentially leading to fewer false-positive results and higher rates of cancer detection (Figure 2).

EFFECTIVENESS OF TOMOSYNTHESIS

There is limited evidence at this time to support the addition of DBT to digital mammography for primary breast cancer screening, with no published randomized trials that assessed outcomes. However, 2 population-based trials in Europe have prospectively assessed DBT plus digital mammography as a primary screening strategy: the Screening With Tomosynthesis or Standard Mammography (STORM) trial⁸ and the Oslo tomosynthesis screening trial.⁵ Only the STORM trial reported first-year interval cancer rates, from which the sensitivity and specificity of DBT plus 2D digital mammography could be calculated and compared with those of 2D digital mammography alone.⁸

In April 2013, the Oslo tomosynthesis screening trial published interim results of its prospective cohort study of 12,631 Norwegian women ages 50 to 69.⁵ Women were invited to participate based on the availability of technical staff and imaging systems at the time of screening, and all participants underwent digital mammography and DBT. Images were read independently by 4 radiologists using a double-reader protocol.

The interim results suggest that adding DBT to digital mammography increased cancer detection rates by 31% and decreased the false-positive rate by 13% compared with 2D digital mammography alone (Table 1). However, the double-reader protocol in this study differs from typical single-reader protocols in the United States, limiting the applicability of the findings.

The STORM trial: Low sensitivity

The STORM trial is a prospective cohort study that included 7,292 women without symptoms, at average risk, age 48 and older, who participated in national breast cancer screening services in northern Italy. Each participant underwent digital mammography and DBT. The examinations were read sequentially (digital mammography first, then DBT plus digital mammography) either by a single radiologist, as is most common in the United States, or by 2 radiologists, as is standard in Europe.

Using the single-reader strategy, adding DBT significantly increased cancer detection rates and reduced the total recall rate (Table 1). Sensitivity was 85% vs 54%, and specificity was 97% vs 96%.^8,9

Of note, the sensitivity of 54% for digital mammography in the STORM trial is substantially lower than the sensitivity of digital mammography reported in the United States.¹⁰

Friedewald et al confirmed Oslo and STORM

To date, the largest US study of DBT plus digital mammography for breast cancer screening was a multicenter retrospective cohort study by Friedewald et al in 2014.¹¹ This study compared cancer detection and recall rates before and after the implementation of DBT at 13 breast centers and evaluated a total of 454,850 examinations (173,663 with DBT plus digital mammography and 281,187 with digital mammography only).

Overall, the recall rate decreased significantly after DBT was adopted and the cancer detection rate increased, findings consistent with those of the STORM and Oslo trials (Table 1). Adding DBT detected invasive cancers at a higher rate than 2D digital mammography alone (4.1/1000 vs 2.9/1,000), while there was no significant difference in ductal carcinoma in situ detection rates. This suggests that the additional cancers detected by DBT may be more clinically important. Nevertheless, the number of biopsies with negative results also increased, suggesting that adding DBT may pose potential harms.

In 2016, Rafferty et al¹² published an additional analysis of the data from Friedewald et al, concluding that adding DBT to 2D digital mammography increased the cancer detection rate more in women with heterogeneously dense breasts than in those with either nondense breasts or extremely dense breasts.¹² The reduction in recall rate was also greatest in the heterogeneously dense subgroup.

Insufficient evidence to recommend

Most other cohort studies comparing DBT and digital mammography have had findings similar to those of the European prospective studies and the large US retrospective cohort study, with the addition of DBT to mammography reducing recall rates and increasing cancer detection rates.¹³ However, many of these studies were subject to potential selection bias and did not provide information on the cancer risk of the participants. In addition, no studies have assessed clinical outcomes such as breast cancer stage at diagnosis or interval cancers, let alone breast cancer mortality.

Rigorous studies need to be done in the United States, using the standard single-reader protocol most often used in this country, to ascertain the clinical outcomes of DBT plus digital mammography for breast cancer screening for women at average risk. A 2016 review cited a dearth of high-quality US studies assessing the role of DBT in primary breast cancer.¹³

The US Preventive Services Task Force, in its 2016 guidelines for breast cancer screening, concluded that there was insufficient evidence to assess the harms and benefits of DBT as a method of breast cancer screening, including adjunctive screening in women with dense breasts.¹

Similarly, the American College of Physicians has advised against screening average-risk women for breast cancer using DBT.¹⁴

APPROVAL, DISSEMINATION, COSTS, AND CHOICE FOR PATIENTS

Even with early promising data suggesting that DBT can increase cancer detection rates and decrease false-positive results when added to routine screening mammography, the rapid diffusion of DBT into clinical practice is outpacing evidence of its effectiveness.⁴ This adoption was spurred in January 2015 when the Centers for Medicare and Medicaid Services added a Current Procedural Terminology code for DBT, allowing for additional reimbursement for it for all mammography indications.¹⁵ Still, the use of DBT in community settings is inconsistent, given the significant up-front costs associated with equipment purchases and variable reimbursement by private insurers who consider the technology experimental.

For the US healthcare system as a whole, it is uncertain whether the purported benefits of DBT will outweigh the additional costs associated with its use. The average reimbursement for a routine digital mammography examination is $135; adding DBT adds an average of $56 to the cost.¹⁵

Using an established, discrete-event breast cancer simulation model, a team of investigators evaluated the cost-effectiveness of combined biennial digital mammography and DBT screening compared with biennial digital mammography screening alone in US women with dense breasts.¹⁶ They found that biennial combined screening is likely to be cost-effective in US women with dense breasts. They also found that for every 2,000 women screened from age 50 to age 74, adding DBT would prevent 1 breast cancer death and 810 false-positive screening examinations.¹⁶

In addition, some have expressed concern that adding DBT to standard digital mammography increases radiation exposure. In fact, the radiation dose with DBT is similar to that with standard 2D digital mammography. Thus, when acquired together, combined digital mammography and DBT screening leads to twice the radiation dose compared with digital mammography alone.¹⁷ Nevertheless, this increased dose remains well below the FDA limits for a screening examination. In addition, the FDA has approved software that allows reconstruction of 2D synthetic views from the 3D data set, which will eventually bring radiation dose levels down to levels comparable to those of conventional digital mammography.¹⁷

Given that DBT is built into newer mammography units and is available as an add-on feature for existing units, its use is likely to increase even faster than digital mammography did when it replaced screen-film mammography in the previous decade.⁴ Its adoption by screening facilities, however, remains variable, and patients wishing to obtain combined DBT and digital mammography screening may have to travel to a different facility from their usual place of screening.¹⁸

Moreover, not all insurance companies cover DBT, resulting in additional out-of-pocket costs to the patient. It is currently unclear how individual facilities are offering DBT services, including how patients are selected for additional DBT and if they are offered the choice to add or forego DBT screening in combination with standard digital mammography.

SUMMARY: AN EMERGING TECHNOLOGY

DBT is an emerging imaging technology that allows the radiologist to view breast images in slices, as in computed tomography. DBT images can be obtained using the same breast compression that women already undergo for 2D digital mammography for breast cancer screening.

At this time, adding DBT to digital mammography screening nearly doubles the radiation exposure to the patient. However, new software is available that allows creation of synthetic 2D views from the 3D data set, resulting in radiation exposure that is similar to conventional digital mammography.

Although there are no published randomized controlled trials assessing the benefit of DBT over 2D digital mammography for breast cancer screening, prospective observational studies suggest that DBT may reduce false-positive recall rates and increase cancer detection rates when used in population-based screening programs. Assuming that additional breast cancer detection contributes to improved clinical outcomes, women with dense breasts may benefit more than women without dense breasts.

No national organizations currently recommend DBT for primary breast cancer screening. Ideally, future studies would determine whether DBT screening reduces breast cancer mortality. Since this research may not be feasible, surrogate clinical outcomes, such as a decrease in interval breast cancer rates and impact on stage at time of diagnosis, would allow us to more confidently recommend this new technology.

Each year, millions of women undergo mammography in the hope of decreasing their risk of dying of breast cancer. The effectiveness of screening mammography, however, continues to be debated.

While most randomized controlled trials have demonstrated significantly lower mortality rates in women who undergo screening, not all trials have. Most experts agree that screening mammography programs decrease breast cancer mortality rates by 12% to 33%.^1,2 But some point out that although mammography programs clearly detect more cases of breast cancer, some proportion of this detection may include “overdiagnosis” of cancers that would not have caused morbidity or mortality, including ductal carcinoma in situ. Also, although deaths from breast cancer have decreased in the United States, at least some of the decrease may be due to more effective treatment rather than early detection.

Moreover, screening has well-documented harms. False-positive results cause alarm and expose women to needless follow-up imaging and biopsies, with their attendant inconvenience, discomfort, risks, and costs. Conversely, false-negative results (especially common in women with dense breasts) lead to missed diagnosis and a false sense of security.

How could programs and technology be improved to make screening more beneficial, both for patients and for society as a whole? A major improvement would be if mammography could be made more sensitive and specific for detecting invasive cancers, with fewer false-positive results. Lower cost and less frequent screening would also be major improvements.

Digital breast tomosynthesis (DBT), also known as 3-dimensional (3D) mammography, may be a way to improve the value of breast cancer screening programs. In 2011, the US Food and Drug Administration (FDA) approved DBT for all mammographic indications, including screening.

WHAT IS TOMOSYNTHESIS?

In DBT, the x-ray source is rotated in an arc around the patient’s breast (Figure 1), generating a 3D image.³ DBT is now routinely built into newer-generation mammography units. The 3D projections of DBT are obtained during the same breast compression required for standard 2D digital mammography. Thus, DBT requires minimal additional time on the part of the patient and the technologist.⁴

The 3D images are processed and sent to a viewing station, where a radiologist can interpret them next to 2D images. The radiologist has the ability to scroll through the DBT projections slice by slice, as in other cross-sectional imaging examinations. However, given the larger number of images compared with digital mammography, DBT requires more time for interpretation, interrupting the workflow. A population-based observational study suggested that combined digital mammography and DBT screening examinations take twice as long to interpret.⁵

The main advantage of DBT is that it can mitigate the problem of overlapping breast tissue on standard digital projections. These areas of focal asymmetry may represent suspicious masses—or merely overlapping breast parenchyma. When areas of focal asymmetry are found on 2D digital mammography without DBT, patients need to come back for further diagnostic imaging to resolve the finding.⁶ In addition, especially in women with dense breasts, areas of overlapping tissue can have a masking effect, obscuring small breast cancers.⁷

Images courtesy of Diana L. Lam, MD, University of Washington, Seattle.

For breast cancer screening, DBT is read in conjunction with standard digital mammography. By allowing examination of the breast parenchyma in thin slices, DBT decreases the interpretive issue of overlapping breast parenchyma and the masking effect, potentially leading to fewer false-positive results and higher rates of cancer detection (Figure 2).

EFFECTIVENESS OF TOMOSYNTHESIS

There is limited evidence at this time to support the addition of DBT to digital mammography for primary breast cancer screening, with no published randomized trials that assessed outcomes. However, 2 population-based trials in Europe have prospectively assessed DBT plus digital mammography as a primary screening strategy: the Screening With Tomosynthesis or Standard Mammography (STORM) trial⁸ and the Oslo tomosynthesis screening trial.⁵ Only the STORM trial reported first-year interval cancer rates, from which the sensitivity and specificity of DBT plus 2D digital mammography could be calculated and compared with those of 2D digital mammography alone.⁸

In April 2013, the Oslo tomosynthesis screening trial published interim results of its prospective cohort study of 12,631 Norwegian women ages 50 to 69.⁵ Women were invited to participate based on the availability of technical staff and imaging systems at the time of screening, and all participants underwent digital mammography and DBT. Images were read independently by 4 radiologists using a double-reader protocol.

The interim results suggest that adding DBT to digital mammography increased cancer detection rates by 31% and decreased the false-positive rate by 13% compared with 2D digital mammography alone (Table 1). However, the double-reader protocol in this study differs from typical single-reader protocols in the United States, limiting the applicability of the findings.

The STORM trial: Low sensitivity

The STORM trial is a prospective cohort study that included 7,292 women without symptoms, at average risk, age 48 and older, who participated in national breast cancer screening services in northern Italy. Each participant underwent digital mammography and DBT. The examinations were read sequentially (digital mammography first, then DBT plus digital mammography) either by a single radiologist, as is most common in the United States, or by 2 radiologists, as is standard in Europe.

Using the single-reader strategy, adding DBT significantly increased cancer detection rates and reduced the total recall rate (Table 1). Sensitivity was 85% vs 54%, and specificity was 97% vs 96%.^8,9

Of note, the sensitivity of 54% for digital mammography in the STORM trial is substantially lower than the sensitivity of digital mammography reported in the United States.¹⁰

Friedewald et al confirmed Oslo and STORM

To date, the largest US study of DBT plus digital mammography for breast cancer screening was a multicenter retrospective cohort study by Friedewald et al in 2014.¹¹ This study compared cancer detection and recall rates before and after the implementation of DBT at 13 breast centers and evaluated a total of 454,850 examinations (173,663 with DBT plus digital mammography and 281,187 with digital mammography only).

Overall, the recall rate decreased significantly after DBT was adopted and the cancer detection rate increased, findings consistent with those of the STORM and Oslo trials (Table 1). Adding DBT detected invasive cancers at a higher rate than 2D digital mammography alone (4.1/1000 vs 2.9/1,000), while there was no significant difference in ductal carcinoma in situ detection rates. This suggests that the additional cancers detected by DBT may be more clinically important. Nevertheless, the number of biopsies with negative results also increased, suggesting that adding DBT may pose potential harms.

In 2016, Rafferty et al¹² published an additional analysis of the data from Friedewald et al, concluding that adding DBT to 2D digital mammography increased the cancer detection rate more in women with heterogeneously dense breasts than in those with either nondense breasts or extremely dense breasts.¹² The reduction in recall rate was also greatest in the heterogeneously dense subgroup.

Insufficient evidence to recommend

Most other cohort studies comparing DBT and digital mammography have had findings similar to those of the European prospective studies and the large US retrospective cohort study, with the addition of DBT to mammography reducing recall rates and increasing cancer detection rates.¹³ However, many of these studies were subject to potential selection bias and did not provide information on the cancer risk of the participants. In addition, no studies have assessed clinical outcomes such as breast cancer stage at diagnosis or interval cancers, let alone breast cancer mortality.

Rigorous studies need to be done in the United States, using the standard single-reader protocol most often used in this country, to ascertain the clinical outcomes of DBT plus digital mammography for breast cancer screening for women at average risk. A 2016 review cited a dearth of high-quality US studies assessing the role of DBT in primary breast cancer.¹³

The US Preventive Services Task Force, in its 2016 guidelines for breast cancer screening, concluded that there was insufficient evidence to assess the harms and benefits of DBT as a method of breast cancer screening, including adjunctive screening in women with dense breasts.¹

Similarly, the American College of Physicians has advised against screening average-risk women for breast cancer using DBT.¹⁴

APPROVAL, DISSEMINATION, COSTS, AND CHOICE FOR PATIENTS

Even with early promising data suggesting that DBT can increase cancer detection rates and decrease false-positive results when added to routine screening mammography, the rapid diffusion of DBT into clinical practice is outpacing evidence of its effectiveness.⁴ This adoption was spurred in January 2015 when the Centers for Medicare and Medicaid Services added a Current Procedural Terminology code for DBT, allowing for additional reimbursement for it for all mammography indications.¹⁵ Still, the use of DBT in community settings is inconsistent, given the significant up-front costs associated with equipment purchases and variable reimbursement by private insurers who consider the technology experimental.

For the US healthcare system as a whole, it is uncertain whether the purported benefits of DBT will outweigh the additional costs associated with its use. The average reimbursement for a routine digital mammography examination is $135; adding DBT adds an average of $56 to the cost.¹⁵

Using an established, discrete-event breast cancer simulation model, a team of investigators evaluated the cost-effectiveness of combined biennial digital mammography and DBT screening compared with biennial digital mammography screening alone in US women with dense breasts.¹⁶ They found that biennial combined screening is likely to be cost-effective in US women with dense breasts. They also found that for every 2,000 women screened from age 50 to age 74, adding DBT would prevent 1 breast cancer death and 810 false-positive screening examinations.¹⁶

In addition, some have expressed concern that adding DBT to standard digital mammography increases radiation exposure. In fact, the radiation dose with DBT is similar to that with standard 2D digital mammography. Thus, when acquired together, combined digital mammography and DBT screening leads to twice the radiation dose compared with digital mammography alone.¹⁷ Nevertheless, this increased dose remains well below the FDA limits for a screening examination. In addition, the FDA has approved software that allows reconstruction of 2D synthetic views from the 3D data set, which will eventually bring radiation dose levels down to levels comparable to those of conventional digital mammography.¹⁷

Given that DBT is built into newer mammography units and is available as an add-on feature for existing units, its use is likely to increase even faster than digital mammography did when it replaced screen-film mammography in the previous decade.⁴ Its adoption by screening facilities, however, remains variable, and patients wishing to obtain combined DBT and digital mammography screening may have to travel to a different facility from their usual place of screening.¹⁸

Moreover, not all insurance companies cover DBT, resulting in additional out-of-pocket costs to the patient. It is currently unclear how individual facilities are offering DBT services, including how patients are selected for additional DBT and if they are offered the choice to add or forego DBT screening in combination with standard digital mammography.

SUMMARY: AN EMERGING TECHNOLOGY

DBT is an emerging imaging technology that allows the radiologist to view breast images in slices, as in computed tomography. DBT images can be obtained using the same breast compression that women already undergo for 2D digital mammography for breast cancer screening.

At this time, adding DBT to digital mammography screening nearly doubles the radiation exposure to the patient. However, new software is available that allows creation of synthetic 2D views from the 3D data set, resulting in radiation exposure that is similar to conventional digital mammography.

Although there are no published randomized controlled trials assessing the benefit of DBT over 2D digital mammography for breast cancer screening, prospective observational studies suggest that DBT may reduce false-positive recall rates and increase cancer detection rates when used in population-based screening programs. Assuming that additional breast cancer detection contributes to improved clinical outcomes, women with dense breasts may benefit more than women without dense breasts.

No national organizations currently recommend DBT for primary breast cancer screening. Ideally, future studies would determine whether DBT screening reduces breast cancer mortality. Since this research may not be feasible, surrogate clinical outcomes, such as a decrease in interval breast cancer rates and impact on stage at time of diagnosis, would allow us to more confidently recommend this new technology.

A healthy 16-year-old boy presented with muscle pain and weakness in the chest and both arms after performing 50 push-ups daily for 3 days, and the symptoms did not seem to improve after 3 days.

EXERCISE-INDUCED RHABDOMYOLYSIS

Approximately 50% of patients with rhabdomyolysis present with the characteristic triad of myalgia (84%), muscle weakness (73%), and dark urine (80%), and 8.1% to 52% present with muscle swelling.¹ Rhabdomyolysis may be caused by exercise,² and risk factors include physical deconditioning, high ambient temperature, high humidity, impaired sweating (due to anticholinergic drugs), sickle cell trait, and hypokalemia from sweating.² Pain and swelling of the affected focal muscles is the chief complaint.³

Although acute renal failure in exercise-induced rhabdomyolysis is rare, failure to recognize rhabdomyolysis can cause diagnostic delay and inappropriate treatment.⁴

In healthy people, exercise-induced muscle damage begins to resolve within 1 to 3 days.^5,6 Physicians should suspect exercise-induced rhabdomyolysis in patients with prolonged muscle swelling and tenderness in affected muscles that lasts longer than expected.⁷

A healthy 16-year-old boy presented with muscle pain and weakness in the chest and both arms after performing 50 push-ups daily for 3 days, and the symptoms did not seem to improve after 3 days.

EXERCISE-INDUCED RHABDOMYOLYSIS

Approximately 50% of patients with rhabdomyolysis present with the characteristic triad of myalgia (84%), muscle weakness (73%), and dark urine (80%), and 8.1% to 52% present with muscle swelling.¹ Rhabdomyolysis may be caused by exercise,² and risk factors include physical deconditioning, high ambient temperature, high humidity, impaired sweating (due to anticholinergic drugs), sickle cell trait, and hypokalemia from sweating.² Pain and swelling of the affected focal muscles is the chief complaint.³

Although acute renal failure in exercise-induced rhabdomyolysis is rare, failure to recognize rhabdomyolysis can cause diagnostic delay and inappropriate treatment.⁴

In healthy people, exercise-induced muscle damage begins to resolve within 1 to 3 days.^5,6 Physicians should suspect exercise-induced rhabdomyolysis in patients with prolonged muscle swelling and tenderness in affected muscles that lasts longer than expected.⁷

A healthy 16-year-old boy presented with muscle pain and weakness in the chest and both arms after performing 50 push-ups daily for 3 days, and the symptoms did not seem to improve after 3 days.

EXERCISE-INDUCED RHABDOMYOLYSIS

Approximately 50% of patients with rhabdomyolysis present with the characteristic triad of myalgia (84%), muscle weakness (73%), and dark urine (80%), and 8.1% to 52% present with muscle swelling.¹ Rhabdomyolysis may be caused by exercise,² and risk factors include physical deconditioning, high ambient temperature, high humidity, impaired sweating (due to anticholinergic drugs), sickle cell trait, and hypokalemia from sweating.² Pain and swelling of the affected focal muscles is the chief complaint.³

Although acute renal failure in exercise-induced rhabdomyolysis is rare, failure to recognize rhabdomyolysis can cause diagnostic delay and inappropriate treatment.⁴

In healthy people, exercise-induced muscle damage begins to resolve within 1 to 3 days.^5,6 Physicians should suspect exercise-induced rhabdomyolysis in patients with prolonged muscle swelling and tenderness in affected muscles that lasts longer than expected.⁷

Take-Home Points

• Torn, displaced, and entrapped UCL is a Stener lesion.
• Hyperabduction injury with pain and joint laxity on examination.
• MRI and ultrasound are useful in evaluating UCL tears.
• Ultrasound offers dynamic evaluation.
• Must be treated appropriately to avoid pain, instability, and osteoarthritis.

In the literature, hyperabduction injuries to the thumb metacarpophalangeal (MCP) joint have been referred to interchangeably as gamekeeper’s thumb and skier’s thumb. Historically, though, gamekeeper’s thumb was initially described in hunters with chronic injury to the ulnar collateral ligament (UCL),¹ and skier’s thumb typically has been described as an acute hyperabduction injury of the UCL.^2-5 The proximal portion of a torn UCL may retract with further abduction and displace dorsally, becoming entrapped by the adductor pollicis aponeurosis insertion, known as a Stener lesion.⁶

The first MCP joint is stabilized by static and dynamic structures that contribute in varying degrees in flexion and extension of the joint. The static stabilizers include the proper and accessory radial and UCLs, the palmar plate, and the dorsal capsule. The UCL originates at the dorsal ulnar aspect of the first metacarpal head at the metacarpal tubercle about 5 mm proximal to the articular surface. The UCL courses distally in the palmar direction to insert volar and proximal to the medial tubercle of the proximal phalanx about 3 mm distal to the articular surface.⁷ In flexion, the proper collateral ligament is taut and is the primary static stabilizer. In extension, the accessory collateral ligament, which inserts on the palmar plate, is taut and is the primary static stabilizer.^8-11

The dynamic stabilizers include the extrinsic muscles (flexor pollicis longus, extensor pollicis longus and brevis) and the intrinsic muscles (abductor pollicis brevis, adductor pollicis, flexor pollicis brevis) inserting on the thumb at the distal phalanx and proximal phalanx and at the base of the first metacarpal.^8-10

Clinical Findings

A 33-year-old healthy man had persistent left hand pain and grip weakness after performing a handstand. He presented to the orthopedic hand clinic 20 days after injury, having failed nonoperative management (use of nonsteroidal anti-inflammatory drugs and soft thumb spica splint). Physical examination revealed soft-tissue swelling and focal tenderness to palpation at the ulnar aspect of the thumb MCP joint. Despite bilateral first MCP joint laxity on varus and valgus stress without identification of a firm endpoint, pain was elicited only on valgus stress of the left first MCP joint. Given the laxity and the left thumb soft-tissue swelling with pain, plain radiographs, ultrasound, and MRI were used to evaluate for severity of presumed left thumb UCL injury.

Imaging Findings

Plain radiographs showed normal bony anatomy without fracture, normal joint space, and mild soft-tissue swelling at the left thumb MCP level (Figures 3A, 3B).

Surgical Findings

Given laxity with pain at the UCL on stress testing, MRI and ultrasound findings, and continued pain and instability of the thumb with pinching and grasping during activities of daily living, the patient and orthopedic hand surgeon proceeded with surgical intervention. Preoperative examination under anesthesia confirmed significant laxity on valgus stress without a palpable endpoint (Figures 5A, 5B).

Discussion

Hyperabduction injuries to the thumb may rupture the UCL of the MCP joint of the thumb or cause a bony avulsion of the base of the proximal phalanx. Injury to the UCL, most often at its distal portion,^4,14,15 may result in a sprain or full-thickness tear of the ligament.

It is vital for the radiologist to identify a Stener lesion because a nondisplaced tear of the UCL is often treated nonsurgically, but UCL tears displaced more than 3 mm and Stener lesions usually must be operated on to avoid chronic instability, pain, and osteoarthritis.^2-5,8,12-23 Sensitivity and specificity of MRI in evaluating UCL injuries are reported to be almost 100%, with resolution of 1 mm using current surface coils.²³ There are various UCL injury patterns, including partial tears, displaced and nondisplaced complete tears, and even complex injuries, such as an incomplete tear with the torn portion retracted as a Stener lesion.²² MRI is needed to establish the extent of injury, as 90% of complete tears that are displaced at least 3 mm, and all tears with retraction proximal and superficial to the aponeurosis (true Stener lesions), failed immobilization and required surgical treatment.²³Although they vary in the literature, mean sensitivity and specificity of ultrasound in detecting UCL tears in level I studies have been reported as 76% and 81%, respectively.²⁴ When Melville and colleagues²¹ applied their ultrasound criteria—including absence of normal UCL fibers traversing the first MCP joint as well as heterogeneous masslike tissue at least partially proximal to the apex of the metacarpal lateral tubercle—they were able to distinguish displaced full-thickness tears from nondisplaced full-thickness tears with 100% accuracy. Hergan and colleagues²⁵ found that the diagnostic accuracy of MRI was superior to that of ultrasound; while MRI accuracy was perfect, 12% of patients were incorrectly diagnosed with ultrasound, with false-positive or false-negative tendon-edge displacement. In our experience, ultrasound is uniquely useful in its ability to characterize the real-time dynamic interaction of the UCL with the adductor aponeurosis. It has been observed that passive flexion of the first interphalangeal joint moves the adductor aponeurosis in isolation, allowing differentiation from the subjacent UCL.²¹ Had a partial tear been in the differential diagnosis of our patient’s Stener lesion, such a maneuver under ultrasound visualization would have solved the dilemma. In addition, ultrasound allows for comparison with the contralateral ligament at the time of examination should a diagnostic dilemma arise.

As many have reported both bony avulsion of the base of the proximal phalanx and concomitant injury to the UCL, identification of a bony avulsion does not exclude a ligamentous injury and the possibility of a Stener lesion (Figure 7).^16,19

Conclusion

A Stener lesion—retraction of a completely torn UCL becoming entrapped dorsally and proximally to the adductor insertion—can cause pain, instability, and ultimately osteoarthritis if not treated appropriately. The orthopedic surgeon should have a high index of suspicion for a Stener lesion in the appropriate clinical scenario and consider all imaging modalities for diagnosis. Likewise, it is of utmost importance for the radiologist to identify imaging findings of a Stener lesion, as physical examination alone may be limited in its ability to characterize injury severity. Both MRI and ultrasound are useful in evaluating UCL tears, and ultrasound provides the additional benefit of dynamic visualization and comparison with the contralateral side.

Am J Orthop. 2017;46(3):E195-E199. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Torn, displaced, and entrapped UCL is a Stener lesion.
• Hyperabduction injury with pain and joint laxity on examination.
• MRI and ultrasound are useful in evaluating UCL tears.
• Ultrasound offers dynamic evaluation.
• Must be treated appropriately to avoid pain, instability, and osteoarthritis.

In the literature, hyperabduction injuries to the thumb metacarpophalangeal (MCP) joint have been referred to interchangeably as gamekeeper’s thumb and skier’s thumb. Historically, though, gamekeeper’s thumb was initially described in hunters with chronic injury to the ulnar collateral ligament (UCL),¹ and skier’s thumb typically has been described as an acute hyperabduction injury of the UCL.^2-5 The proximal portion of a torn UCL may retract with further abduction and displace dorsally, becoming entrapped by the adductor pollicis aponeurosis insertion, known as a Stener lesion.⁶

The first MCP joint is stabilized by static and dynamic structures that contribute in varying degrees in flexion and extension of the joint. The static stabilizers include the proper and accessory radial and UCLs, the palmar plate, and the dorsal capsule. The UCL originates at the dorsal ulnar aspect of the first metacarpal head at the metacarpal tubercle about 5 mm proximal to the articular surface. The UCL courses distally in the palmar direction to insert volar and proximal to the medial tubercle of the proximal phalanx about 3 mm distal to the articular surface.⁷ In flexion, the proper collateral ligament is taut and is the primary static stabilizer. In extension, the accessory collateral ligament, which inserts on the palmar plate, is taut and is the primary static stabilizer.^8-11

The dynamic stabilizers include the extrinsic muscles (flexor pollicis longus, extensor pollicis longus and brevis) and the intrinsic muscles (abductor pollicis brevis, adductor pollicis, flexor pollicis brevis) inserting on the thumb at the distal phalanx and proximal phalanx and at the base of the first metacarpal.^8-10

Clinical Findings

A 33-year-old healthy man had persistent left hand pain and grip weakness after performing a handstand. He presented to the orthopedic hand clinic 20 days after injury, having failed nonoperative management (use of nonsteroidal anti-inflammatory drugs and soft thumb spica splint). Physical examination revealed soft-tissue swelling and focal tenderness to palpation at the ulnar aspect of the thumb MCP joint. Despite bilateral first MCP joint laxity on varus and valgus stress without identification of a firm endpoint, pain was elicited only on valgus stress of the left first MCP joint. Given the laxity and the left thumb soft-tissue swelling with pain, plain radiographs, ultrasound, and MRI were used to evaluate for severity of presumed left thumb UCL injury.

Imaging Findings

Plain radiographs showed normal bony anatomy without fracture, normal joint space, and mild soft-tissue swelling at the left thumb MCP level (Figures 3A, 3B).

Surgical Findings

Given laxity with pain at the UCL on stress testing, MRI and ultrasound findings, and continued pain and instability of the thumb with pinching and grasping during activities of daily living, the patient and orthopedic hand surgeon proceeded with surgical intervention. Preoperative examination under anesthesia confirmed significant laxity on valgus stress without a palpable endpoint (Figures 5A, 5B).

Discussion

Hyperabduction injuries to the thumb may rupture the UCL of the MCP joint of the thumb or cause a bony avulsion of the base of the proximal phalanx. Injury to the UCL, most often at its distal portion,^4,14,15 may result in a sprain or full-thickness tear of the ligament.

It is vital for the radiologist to identify a Stener lesion because a nondisplaced tear of the UCL is often treated nonsurgically, but UCL tears displaced more than 3 mm and Stener lesions usually must be operated on to avoid chronic instability, pain, and osteoarthritis.^2-5,8,12-23 Sensitivity and specificity of MRI in evaluating UCL injuries are reported to be almost 100%, with resolution of 1 mm using current surface coils.²³ There are various UCL injury patterns, including partial tears, displaced and nondisplaced complete tears, and even complex injuries, such as an incomplete tear with the torn portion retracted as a Stener lesion.²² MRI is needed to establish the extent of injury, as 90% of complete tears that are displaced at least 3 mm, and all tears with retraction proximal and superficial to the aponeurosis (true Stener lesions), failed immobilization and required surgical treatment.²³Although they vary in the literature, mean sensitivity and specificity of ultrasound in detecting UCL tears in level I studies have been reported as 76% and 81%, respectively.²⁴ When Melville and colleagues²¹ applied their ultrasound criteria—including absence of normal UCL fibers traversing the first MCP joint as well as heterogeneous masslike tissue at least partially proximal to the apex of the metacarpal lateral tubercle—they were able to distinguish displaced full-thickness tears from nondisplaced full-thickness tears with 100% accuracy. Hergan and colleagues²⁵ found that the diagnostic accuracy of MRI was superior to that of ultrasound; while MRI accuracy was perfect, 12% of patients were incorrectly diagnosed with ultrasound, with false-positive or false-negative tendon-edge displacement. In our experience, ultrasound is uniquely useful in its ability to characterize the real-time dynamic interaction of the UCL with the adductor aponeurosis. It has been observed that passive flexion of the first interphalangeal joint moves the adductor aponeurosis in isolation, allowing differentiation from the subjacent UCL.²¹ Had a partial tear been in the differential diagnosis of our patient’s Stener lesion, such a maneuver under ultrasound visualization would have solved the dilemma. In addition, ultrasound allows for comparison with the contralateral ligament at the time of examination should a diagnostic dilemma arise.

As many have reported both bony avulsion of the base of the proximal phalanx and concomitant injury to the UCL, identification of a bony avulsion does not exclude a ligamentous injury and the possibility of a Stener lesion (Figure 7).^16,19

Conclusion

A Stener lesion—retraction of a completely torn UCL becoming entrapped dorsally and proximally to the adductor insertion—can cause pain, instability, and ultimately osteoarthritis if not treated appropriately. The orthopedic surgeon should have a high index of suspicion for a Stener lesion in the appropriate clinical scenario and consider all imaging modalities for diagnosis. Likewise, it is of utmost importance for the radiologist to identify imaging findings of a Stener lesion, as physical examination alone may be limited in its ability to characterize injury severity. Both MRI and ultrasound are useful in evaluating UCL tears, and ultrasound provides the additional benefit of dynamic visualization and comparison with the contralateral side.

Am J Orthop. 2017;46(3):E195-E199. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Torn, displaced, and entrapped UCL is a Stener lesion.
• Hyperabduction injury with pain and joint laxity on examination.
• MRI and ultrasound are useful in evaluating UCL tears.
• Ultrasound offers dynamic evaluation.
• Must be treated appropriately to avoid pain, instability, and osteoarthritis.

In the literature, hyperabduction injuries to the thumb metacarpophalangeal (MCP) joint have been referred to interchangeably as gamekeeper’s thumb and skier’s thumb. Historically, though, gamekeeper’s thumb was initially described in hunters with chronic injury to the ulnar collateral ligament (UCL),¹ and skier’s thumb typically has been described as an acute hyperabduction injury of the UCL.^2-5 The proximal portion of a torn UCL may retract with further abduction and displace dorsally, becoming entrapped by the adductor pollicis aponeurosis insertion, known as a Stener lesion.⁶

The first MCP joint is stabilized by static and dynamic structures that contribute in varying degrees in flexion and extension of the joint. The static stabilizers include the proper and accessory radial and UCLs, the palmar plate, and the dorsal capsule. The UCL originates at the dorsal ulnar aspect of the first metacarpal head at the metacarpal tubercle about 5 mm proximal to the articular surface. The UCL courses distally in the palmar direction to insert volar and proximal to the medial tubercle of the proximal phalanx about 3 mm distal to the articular surface.⁷ In flexion, the proper collateral ligament is taut and is the primary static stabilizer. In extension, the accessory collateral ligament, which inserts on the palmar plate, is taut and is the primary static stabilizer.^8-11

The dynamic stabilizers include the extrinsic muscles (flexor pollicis longus, extensor pollicis longus and brevis) and the intrinsic muscles (abductor pollicis brevis, adductor pollicis, flexor pollicis brevis) inserting on the thumb at the distal phalanx and proximal phalanx and at the base of the first metacarpal.^8-10

Clinical Findings

A 33-year-old healthy man had persistent left hand pain and grip weakness after performing a handstand. He presented to the orthopedic hand clinic 20 days after injury, having failed nonoperative management (use of nonsteroidal anti-inflammatory drugs and soft thumb spica splint). Physical examination revealed soft-tissue swelling and focal tenderness to palpation at the ulnar aspect of the thumb MCP joint. Despite bilateral first MCP joint laxity on varus and valgus stress without identification of a firm endpoint, pain was elicited only on valgus stress of the left first MCP joint. Given the laxity and the left thumb soft-tissue swelling with pain, plain radiographs, ultrasound, and MRI were used to evaluate for severity of presumed left thumb UCL injury.

Imaging Findings

Plain radiographs showed normal bony anatomy without fracture, normal joint space, and mild soft-tissue swelling at the left thumb MCP level (Figures 3A, 3B).

Surgical Findings

Given laxity with pain at the UCL on stress testing, MRI and ultrasound findings, and continued pain and instability of the thumb with pinching and grasping during activities of daily living, the patient and orthopedic hand surgeon proceeded with surgical intervention. Preoperative examination under anesthesia confirmed significant laxity on valgus stress without a palpable endpoint (Figures 5A, 5B).

Discussion

Hyperabduction injuries to the thumb may rupture the UCL of the MCP joint of the thumb or cause a bony avulsion of the base of the proximal phalanx. Injury to the UCL, most often at its distal portion,^4,14,15 may result in a sprain or full-thickness tear of the ligament.

It is vital for the radiologist to identify a Stener lesion because a nondisplaced tear of the UCL is often treated nonsurgically, but UCL tears displaced more than 3 mm and Stener lesions usually must be operated on to avoid chronic instability, pain, and osteoarthritis.^2-5,8,12-23 Sensitivity and specificity of MRI in evaluating UCL injuries are reported to be almost 100%, with resolution of 1 mm using current surface coils.²³ There are various UCL injury patterns, including partial tears, displaced and nondisplaced complete tears, and even complex injuries, such as an incomplete tear with the torn portion retracted as a Stener lesion.²² MRI is needed to establish the extent of injury, as 90% of complete tears that are displaced at least 3 mm, and all tears with retraction proximal and superficial to the aponeurosis (true Stener lesions), failed immobilization and required surgical treatment.²³Although they vary in the literature, mean sensitivity and specificity of ultrasound in detecting UCL tears in level I studies have been reported as 76% and 81%, respectively.²⁴ When Melville and colleagues²¹ applied their ultrasound criteria—including absence of normal UCL fibers traversing the first MCP joint as well as heterogeneous masslike tissue at least partially proximal to the apex of the metacarpal lateral tubercle—they were able to distinguish displaced full-thickness tears from nondisplaced full-thickness tears with 100% accuracy. Hergan and colleagues²⁵ found that the diagnostic accuracy of MRI was superior to that of ultrasound; while MRI accuracy was perfect, 12% of patients were incorrectly diagnosed with ultrasound, with false-positive or false-negative tendon-edge displacement. In our experience, ultrasound is uniquely useful in its ability to characterize the real-time dynamic interaction of the UCL with the adductor aponeurosis. It has been observed that passive flexion of the first interphalangeal joint moves the adductor aponeurosis in isolation, allowing differentiation from the subjacent UCL.²¹ Had a partial tear been in the differential diagnosis of our patient’s Stener lesion, such a maneuver under ultrasound visualization would have solved the dilemma. In addition, ultrasound allows for comparison with the contralateral ligament at the time of examination should a diagnostic dilemma arise.

As many have reported both bony avulsion of the base of the proximal phalanx and concomitant injury to the UCL, identification of a bony avulsion does not exclude a ligamentous injury and the possibility of a Stener lesion (Figure 7).^16,19

Conclusion

A Stener lesion—retraction of a completely torn UCL becoming entrapped dorsally and proximally to the adductor insertion—can cause pain, instability, and ultimately osteoarthritis if not treated appropriately. The orthopedic surgeon should have a high index of suspicion for a Stener lesion in the appropriate clinical scenario and consider all imaging modalities for diagnosis. Likewise, it is of utmost importance for the radiologist to identify imaging findings of a Stener lesion, as physical examination alone may be limited in its ability to characterize injury severity. Both MRI and ultrasound are useful in evaluating UCL tears, and ultrasound provides the additional benefit of dynamic visualization and comparison with the contralateral side.

Am J Orthop. 2017;46(3):E195-E199. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

To the Editor: In their Clinical Picture article in the February 2017 issue, Barbaryan et al¹ describe brain lesions in a young woman with human immunodeficiency virus infection who presented with seizures. Figure 3 illustrates Grocott-Gomori methenamine silver (GMS)-positive fungal organisms in a brain biopsy. The organisms appear helmet-shaped and crescent-shaped and contain an intracystic dot, morphologic features of Pneumocystis jiroveci cysts.² We could not appreciate features of Histoplasma yeasts (smaller yeasts with diameter of 3 to 5 μm, oval to tapered shape, and narrow-based budding).

The distinction between the two organisms can occasionally be challenging because there is some degree of overlap in size and shape, and both are GMS-positive. It is interesting that in the current case, serologic studies for Histoplasma were positive. Multiple infections with opportunistic organisms are not uncommon in severely immunocompromised individuals, and it is possible that the patient may also have had concurrent histoplasmosis. Brain lesions caused by Pneumocystis, although rare, have been previously reported.^3–5 Immunohistochemistry for Pneumocystis may be of interest in this very unusual case.

[Editor’s note: Letters that comment on articles published in the Journal are sent to the author(s) for response. In this case, the authors felt that the letter did not require a reply.]

To the Editor: In their Clinical Picture article in the February 2017 issue, Barbaryan et al¹ describe brain lesions in a young woman with human immunodeficiency virus infection who presented with seizures. Figure 3 illustrates Grocott-Gomori methenamine silver (GMS)-positive fungal organisms in a brain biopsy. The organisms appear helmet-shaped and crescent-shaped and contain an intracystic dot, morphologic features of Pneumocystis jiroveci cysts.² We could not appreciate features of Histoplasma yeasts (smaller yeasts with diameter of 3 to 5 μm, oval to tapered shape, and narrow-based budding).

The distinction between the two organisms can occasionally be challenging because there is some degree of overlap in size and shape, and both are GMS-positive. It is interesting that in the current case, serologic studies for Histoplasma were positive. Multiple infections with opportunistic organisms are not uncommon in severely immunocompromised individuals, and it is possible that the patient may also have had concurrent histoplasmosis. Brain lesions caused by Pneumocystis, although rare, have been previously reported.^3–5 Immunohistochemistry for Pneumocystis may be of interest in this very unusual case.

[Editor’s note: Letters that comment on articles published in the Journal are sent to the author(s) for response. In this case, the authors felt that the letter did not require a reply.]

To the Editor: In their Clinical Picture article in the February 2017 issue, Barbaryan et al¹ describe brain lesions in a young woman with human immunodeficiency virus infection who presented with seizures. Figure 3 illustrates Grocott-Gomori methenamine silver (GMS)-positive fungal organisms in a brain biopsy. The organisms appear helmet-shaped and crescent-shaped and contain an intracystic dot, morphologic features of Pneumocystis jiroveci cysts.² We could not appreciate features of Histoplasma yeasts (smaller yeasts with diameter of 3 to 5 μm, oval to tapered shape, and narrow-based budding).

The distinction between the two organisms can occasionally be challenging because there is some degree of overlap in size and shape, and both are GMS-positive. It is interesting that in the current case, serologic studies for Histoplasma were positive. Multiple infections with opportunistic organisms are not uncommon in severely immunocompromised individuals, and it is possible that the patient may also have had concurrent histoplasmosis. Brain lesions caused by Pneumocystis, although rare, have been previously reported.^3–5 Immunohistochemistry for Pneumocystis may be of interest in this very unusual case.

[Editor’s note: Letters that comment on articles published in the Journal are sent to the author(s) for response. In this case, the authors felt that the letter did not require a reply.]

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenter

Timothy Kasprzak, MD, MBA
 

Session summary

“What imaging study should I order for this patient?” is a question that comes up frequently in the hospital. Dr. Kasprzak, the director of abdominopelvic and oncologic imaging at Case Western MetroHealth, Cleveland, offered some practical advice for inpatient clinicians during a rapid-fire session at HM17.

Key takeaways for HM

• Utilize appropriate use criteria (such as offered by the ACR) for choosing the most worthwhile imaging study.

• Give relevant clinical history in your order to help the radiologist narrow the differential (and to help prevent the “clinically correlate” phrase as much as possible).

• Consider the risk/benefit of contrast use for all patients getting CT or MRI studies.

• Avoid the use of inpatient PET scans, except for very specific indications (such as obscure infections).

Dr. Sehgal is a hospitalist at the South Texas Veterans Health Care System in San Antonio, an associate professor of medicine at University of Texas Health-San Antonio, and a an editorial board member of The Hospitalist.

Presenters

Nilam Soni, MD, FHM; Thomas Conlon, MD; Ria Dancel, MD, FAAP, FHM; Daniel Schnobrich, MD

Summary

Point-of-care ultrasound (POCUS) is rapidly gaining acceptance in the medical community as a goal-directed examination that answers a specific diagnostic question or guides a bedside invasive procedure. Adoption by pediatric hospitalists is increasing, aided by multiple training pathways, opportunities for scholarship, and organization development.

The use of POCUS is increasing among nonradiologist physicians due to the expectation for perfection, desire for improved patient experience, and increased availability of ultrasound machines. POCUS is rapid and safe, and can be used serially to monitor, provide procedural guidance, and lead to initiation of appropriate therapies.

Key takeaways for HM

• Point-of-care ultrasound (POCUS) is rapidly being adopted by pediatric hospitalists.
• Pediatric applications are still being developed, but include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia/associated effusions, and IV placement.
• Initial training can be provided by pediatric ED physicians/PICU physicians or an on-site commercial course can be arranged for larger groups.
• Relationships with radiologists should be established at the outset to avoid misunderstanding of POCUS.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital and is the pediatric editor of The Hospitalist.

Presenters

Nilam Soni, MD, FHM; Thomas Conlon, MD; Ria Dancel, MD, FAAP, FHM; Daniel Schnobrich, MD

Summary

Point-of-care ultrasound (POCUS) is rapidly gaining acceptance in the medical community as a goal-directed examination that answers a specific diagnostic question or guides a bedside invasive procedure. Adoption by pediatric hospitalists is increasing, aided by multiple training pathways, opportunities for scholarship, and organization development.

The use of POCUS is increasing among nonradiologist physicians due to the expectation for perfection, desire for improved patient experience, and increased availability of ultrasound machines. POCUS is rapid and safe, and can be used serially to monitor, provide procedural guidance, and lead to initiation of appropriate therapies.

Key takeaways for HM

• Point-of-care ultrasound (POCUS) is rapidly being adopted by pediatric hospitalists.
• Pediatric applications are still being developed, but include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia/associated effusions, and IV placement.
• Initial training can be provided by pediatric ED physicians/PICU physicians or an on-site commercial course can be arranged for larger groups.
• Relationships with radiologists should be established at the outset to avoid misunderstanding of POCUS.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital and is the pediatric editor of The Hospitalist.

Presenters

Nilam Soni, MD, FHM; Thomas Conlon, MD; Ria Dancel, MD, FAAP, FHM; Daniel Schnobrich, MD

Summary

Point-of-care ultrasound (POCUS) is rapidly gaining acceptance in the medical community as a goal-directed examination that answers a specific diagnostic question or guides a bedside invasive procedure. Adoption by pediatric hospitalists is increasing, aided by multiple training pathways, opportunities for scholarship, and organization development.

The use of POCUS is increasing among nonradiologist physicians due to the expectation for perfection, desire for improved patient experience, and increased availability of ultrasound machines. POCUS is rapid and safe, and can be used serially to monitor, provide procedural guidance, and lead to initiation of appropriate therapies.

Key takeaways for HM

• Point-of-care ultrasound (POCUS) is rapidly being adopted by pediatric hospitalists.
• Pediatric applications are still being developed, but include guidance of bladder catheterization, identifying occult abscesses, diagnosis of pneumonia/associated effusions, and IV placement.
• Initial training can be provided by pediatric ED physicians/PICU physicians or an on-site commercial course can be arranged for larger groups.
• Relationships with radiologists should be established at the outset to avoid misunderstanding of POCUS.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital and is the pediatric editor of The Hospitalist.