Naclerio’s V sign and continuous diaphragm sign after endoscopy

Description

An otherwise healthy 72-year-old woman presented with dyspnoea and systemic subcutaneous emphysema. She had undergone upper endoscopy, in which duodenal ulcer was found. The community hospital where the endoscopy was conducted transferred her to our tertiary hospital for further diagnosis and management. On arrival, she complained of severe difficulty in breathing; massive subcutaneous emphysema on her chest to the feet was observed on palpation. Chest X-ray image showed Naclerio’s V sign (figure 1A, black arrow) and continuous diaphragm sign (figure 1A, white arrows). CT scan confirmed massive subcutaneous and mediastinal emphysema with pneumothorax, pneumopericardium and free air in retroperitoneal space (figure 1B,C). Emergent laparotomy revealed duodenal perforation, 9 mm in diameter at the descending part of duodenum (figure 1D, white arrow), and was surgically repaired. After the surgery, the emphysema gradually disappeared in weeks and had not recurred at 6-month follow-up.

Figure 1.

(A) Plain chest radiograph with Naclerio’s V sign (black arrow) and continuous diaphragm sign (white arrows). (B) CT image showing pneumothorax, pneumomediastinum and subcutaneous emphysema. (C) Free air was observed in retroperitoneal space. (D) Duodenal perforation (white arrow) was revealed in laparotomy.

Endoscopic or surgical procedures can induce gastrointestinal perforation as its complication. Depending on the perforated site, it would result in different clinical findings such as pneumoperitoneum,¹ pneumopericardium,² pneumothorax and mediastinal emphysema. Except for its proximal portion next to the stomach, most part of the duodenum is buried into retroperitoneal space. Thus, a duodenum perforation can induce retroperitoneal emphysema as in the present case, or pneumoperitoneum otherwise, depending on the perforation site. Naclerio’s V sign, which was originally reported as a sign indicating spontaneous oesophageal rupture,³ sometimes gives us a clue of mediastinal emphysema on the chest plain film. Rapid diagnosis of gastrointestinal tract perforation generally leads to prompt surgical intervention, which is required to realise better outcome.

Learning points.

• Remember gastrointestinal perforation as a complication of endoscopic procedure.

• A duodenum perforation can induce either retroperitoneal emphysema or pneumoperitoneum, depending on the perforation site.

• Physicians should suspect upper gastrointestinal perforation when they encounter specific signs in plain X-ray image: Naclerio’s V sign and/or continuous diaphragm sign.