PMC9619327_01
Fluoroscopic image from an upper gastrointestinal series demonstrating a small focus of possible extraluminal contrast adjacent to the duodenojejunostomy site (white arrows), potentially representing a leak.
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An upper gastrointestinal fluoroscopy series with iodinated oral contrast was ordered (Fig. 1).
(A) (left) Axial slice of a dual energy CT abdomen/pelvis without IV contrast but with oral iodinated contrast demonstrating no clear presence of anastomotic leak. It was initially unclear whether the high-attenuation inside the transverse slice of tubing (white arrows) represents beam-hardening artifact from the barium strip or if it was due to iodinated contrast leakage. (B) (right) Iodine overlay reconstruction of Fig. 2A (where red is color coded to the multi-energy spectrum of iodine) demonstrating material in the surgical drain tubing contents contain iodinated contrast (white arrows) in the absence of a clear anastomotic leak source. Potentially this iodine source may have been remnant from the earlier fluoroscopic study that had had time to collect in the drain.
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An initial interpretation of the conventional CT found no obvious contrast leak, but the contents of the tubing appeared hyper-attenuating (Figs. 2A and 3A). However, using the iodine overlay reconstruction from the dual energy CT, it was apparent that the tube contained iodine and was not simply associated with the barium strip, suggesting an anastomotic leak (Figs. 2B and 3B).
(A): (left) Axial slice of a dual energy CT abdomen/pelvis without IV contrast but with oral iodinated contrast demonstrating no clear presence of anastomotic leak. The white arrows point to a longitudinal slice of the tubing, again demonstrating that the hyper-attenuation within the tube looks similar to artifact from the Barium strip. (B): (right) Iodine overlay reconstruction of Fig. 3A demonstrating attenuation of the surgical drain tubing contents clearly eccentric from the barium strip (white arrows).
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An initial interpretation of the conventional CT found no obvious contrast leak, but the contents of the tubing appeared hyper-attenuating (Figs. 2A and 3A). However, using the iodine overlay reconstruction from the dual energy CT, it was apparent that the tube contained iodine and was not simply associated with the barium strip, suggesting an anastomotic leak (Figs. 2B and 3B).
CT axial images of a syringe filled with saline (left) and a syringe filled with the serosanguinous output of surgical drainage (68 HU), which is over twice as dense as the saline (29 HU).
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In order further confirm the presence of an anastomotic leak, the contents of the surgical drain were placed in a syringe and rescanned in the CT (next to a syringe of normal saline as a control) (Fig. 4).