Picture Diagnosis

Q 34 years old male presented to the ED after hours of partying at a local bar, where he started puking due to a large intake of alcohol. CXR on arrival is below.

Answer: The V-sign of Naclerio

The V-sign of Naclerio (see Arrows in the picture above) is present in approximately one-fourth of patients with esophageal perforation. These are radiolucent streaks of air that dissect the fascial planes behind the heart to form the shape of the letter V. It is a relatively specific radiographic sign of esophageal perforation.

Decades ago, when CXR was a luxury in ED, this was considered an early sign of esophageal rupture (see reference # 2).

#GI

#surgical-critical-care

References:

1. Komaru Y, Maeda A. Naclerio's V sign and continuous diaphragm sign after endoscopy. BMJ Case Rep. 2018 Sep 21;2018:bcr2018226021. doi: 10.1136/bcr-2018-226021. PMID: 30244226; PMCID: PMC6157589.

2. NACLERIO EA. The V sign in the diagnosis of spontaneous rupture of the esophagus (an early roentgen clue). Am J Surg. 1957 Feb;93(2):291-8. doi: 10.1016/0002-9610(57)90781-x. PMID: 13394807.