Diagnosis: Esophageal Perforation

CT angiogram of the patient's chest revealed extensive pneumomediastinum with mural thickening and mural air within the distal esophagus in addition to adjacent air-fluid levels. Findings suggestive of esophageal perforation including Boerhaave syndrome.

Surgery was urgently consulted and the patient taken to the OR where he underwent primary repair of a distal esophageal perforation and removal of an impacted bezoar with EGD. The patient did well post-operatively and was discharged in stable condition on hospital day 4. 

Esophageal Perforation - Rapid Fire

• Most common cause of esophageal perforation --> endoscopy 

• Other causes of esophageal perforation:
• foreign body ingestion
• caustic substance ingestion
• severe esophagitis
• carcinoma
• direct injury related to blunt or penetrating trauma

• Pathophysiology of Boerhaave syndrome --> rapid increase in intraesophageal pressure related to forceful vomiting  

• More than 90% of spontaneous esophageal ruptures occur in the distal esophagus 

• Mackler's triad is pathognomonic for spontaneous esophageal rupture
• subcutaneous emphysema
• chest pain
• vomiting

• Pain associated with distal esophageal rupture often radiates to the back 

• Hamman's sign or crunch = "crunching" sound auscultated over chest, pathognomonic for mediastinal emphysema 

• Diagnose with esophagram and/or CT chest

• Misdiagnosis occurs in half of patients because of the broad differential of chest and abdominal pain

• Management
• broad-spectrum antibiotics
• NPO
• urgent surgical consult
• growing body of evidence suggests small, contained iatrogenic perforations can be managed conservatively without surgery

• Outcome (Kiernan PD, Thoracic esophageal perforations. Am Surg. 76:1355-1362 2010)
• 97% survival rate with treatment in first 24 hours
• 89% with treatment after 24 hours

References: 

Rosen's Emergency Medicine Concepts and Clinical Practice, 8th Ed, 2014, Chapter 89: Esophagus, Stomach, and Duodenum by Jamie M. Hess and Mark J. Lowell

Indigestion

Happy New Year! Here is the first case of 2015. 

A 51yo male with history of GERD is brought in by advanced life support ambulance for severe abdominal pain. Paramedics report the patient appeared diaphoretic on arrival, otherwise has maintained stable vital signs in transit. The patient describes the pain as radiating to his back with associated shortness of breath and states it is "the worst pain of my life." He denies having any nausea or vomiting. On further questioning he endorses a history of multiple endoscopies in the past for his GERD, the most recent being 3 years ago. He took Prilosec this morning before eating a breakfast of oatmeal and bacon after which he felt like something was stuck in his throat with onset of severe pain. 

On exam the patient is a well-nourished middle-aged male, diaphoretic, in moderate distress and clutching his chest. He has clear breath sounds bilaterally. Normal heart sounds. His abdomen is soft and tender in the epigastrium without rebound or guarding. 

ECG shows sinus tachycardia without signs of ischemia. Laboratory tests are pending. The patient's pain mildly improves with 1 mg IV Dilaudid given twice. You decide to order a CT scan of the patient's chest which is shown below: 

What is the diagnosis?

Please leave a comment below and share with us how you would manage this patient.

The diagnosis for this case will be posted in approximately 1 week.