- Identify soft tissue abnormalities on chest x-ray
A 30 yo M with cyclic vomiting syndrome comes in with 3 days of worsening nausea/vomiting and 1 day of chest pain and shortness of breath. He reports 30 episodes of emesis over the past 3 days, initially bilious, but his most recent episodes have had small amounts of blood. He reports subjective fevers, chills, diaphoresis and new onset chest pain, neck pain and shortness of breath over the past day. He additionally reports new hoarseness over the past day.
His vital signs are notable for T 37.7C, HR 120s, BPs 130/80, RR 22, SaO2 95% on RA. His initial labs are notable for WBC of 32 with left shift, hct of 39. CMP, lipase, and coagulation markers are normal.
His chest x-ray shows the following:
What is your differential for this finding?
Subcutaneous emphysema and pneumomediastinum suggest either airway or esophageal (the two air containing structures in the mediastium) perforation. Given his history of severe nausea/vomiting, concern was highest for esophageal perforation, or Boerhaave’s syndrome.
Mallory-Weiss syndrome can also occur in people with a history of recurrent and forceful retching and vomiting. This syndrome is caused by mucosal lacerations without perforation so mediastinal or subcutaneous air is not seen on CXR. This typically presents with hematemesis.
What is your next step in diagnosis?
A gastrograffin XR esophagram is needed for diagnosis of an esophageal perforation. It reveals the location and extent of perforation. Barium should not be used because it is irritative if it extravasates into the mediastinum.
A CT chest +/- abdomen can be used if no area of perforation is easily identified on the esophagram but is not first line for diagnosis.
How would you manage him now?
Patients with Boerhaave’s have high mortality of 20-40%.1 should receive the following interventions immediately:
- Strict NPO
- IV PPI
- Broad spectrum antimicrobial coverage
- Should cover oral flora (streptococcal species, gram negatives) and anaerobes – e.g., Zosyn, Unasyn, fluoroquinolone + flagyl
- Though not consistently recommended in the literature, recommend additionally covering for Candida, which colonizes the GI tract – e.g., fluconazole
- Thoracic surgery consult
- Some cases are managed conservatively or endoscopically (i.e., with esophageal stent placement), but most cases require surgical intervention.
- No consistent data to suggest “nitrogen washout,” or delivering 100% FiO2 to help with reabsorption of mediastinal and subcutaneous air
This patient was started on levofloxacin + flagyl + fluconazole because of a penicillin allergy. He was made strictly NPO. Thoracic surgery was consulted for management and he was put on 100% FiO2.
DIAGNOSIS AND OUTCOME:
BOOERHAAVE’S SYNDROME (SPONTANEOUS ESOPHAGEAL RUPTURE)
This classically presents with Mackler’s triad – vomiting, chest pain and subcutaneous emphysema. However, this finding is only present in ~ 50% of all cases.2 Subcutaneous emphysema can be seen in 60% of cases, but is not present on initial rupture. Symptoms depends on the location of the rupture. Cervical esophagus perforations result in neck pain and stiffness and lower esophagus perforations can result in peritonitis and abdominal pain.2
His gastrograffin study showed a contained lower esophageal tear without active extravasation into the pleural space. It is presumed he had some perforation that was contained to cause the pneumomediastinum and subcutaneous air.
He was managed conservatively without need for surgical or endoscopic management. CT scan of the chest showed a retropharyngeal/mediastinal phlegmon and he was continued on broad spectrum antibiotic therapy with levofloxacin/flagyl. He clinically improved and had a repeat esophagram at discharge which showed healed esophageal tear.
TAKE HOME POINTS:
- Suspect Boerhaave’s syndrome, esophageal rupture, in patients with a history of vomiting and chest pain, neck pain, hoarseness and/or subcutaneous emphysema.
- Patients with suspected Boerhaave’s should be made strict NPO, placed on IV PPI therapy and covered with broad spectrum antibiotics and anti-fungals.
- Gastrograffin esophagram is the study of choice to detect esophageal rupture.
- Thoracic surgery should be consulted early to determine need for surgical intervention.
- Blencowe, NS. 2013. Spontaneous oesophgaeal rupture. BMJ. 346;f3095.
- Kaman L et al. Management of Esophageal Perforation in Adults. Gastroenterology Res. 2010 Dec; 3(6): 235–244.