An 80-year-old hospitalized woman is evaluated for chest pressure and dyspnea. The patient has advanced stage lung cancer and was admitted 3 days ago for chemotherapy. Her hospital course was complicated by severe nausea and vomiting and an episode of supraventricular tachycardia. On the third day of hospitalization, she complains of chest pressure, epigastric pain, and difficulty breathing. Her other medical problems include type 2 diabetes mellitus, hypertension, and mild diastolic dysfunction.
Her temperature is 38.9 C (102 F), blood pressure is 92/40 mm Hg, pulse is 112 /min, and respirations are 24 /min. The patient's pulse oximetry shows 89% on a nonrebreathing mask. Examination reveals scattered bilateral rhonchi and dullness to percussion over the left base. Her abdomen is soft but tender.
Her laboratory results are as follows:

Portable chest X-ray shows a moderate left-sided pleural effusion and a retrocardiac air shadow, both of which are new findings compared to the study done one day prior.
Which of the following is most helpful in diagnosing her current condition?

Question

An 80-year-old hospitalized woman is evaluated for chest pressure and dyspnea.  The patient has advanced stage lung cancer and was admitted 3 days ago for chemotherapy.  Her hospital course was complicated by severe nausea and vomiting and an episode of supraventricular tachycardia.  On the third day of hospitalization, she complains of chest pressure, epigastric pain, and difficulty breathing.  Her other medical problems include type 2 diabetes mellitus, hypertension, and mild diastolic dysfunction.
Her temperature is 38.9 C (102 F), blood pressure is 92/40 mm Hg, pulse is 112 /min, and respirations are 24 /min.  The patient's pulse oximetry shows 89% on a nonrebreathing mask.  Examination reveals scattered bilateral rhonchi and dullness to percussion over the left base.  Her abdomen is soft but tender.
Her laboratory results are as follows:

Portable chest X-ray shows a moderate left-sided pleural effusion and a retrocardiac air shadow, both of which are new findings compared to the study done one day prior.
Which of the following is most helpful in diagnosing her current condition?

Quizplus · Accepted Answer

This patient's presentation is consistent with Boerhaave syndrome, also known as esophageal rupture. Patients typically present with forceful vomiting followed by chest pain and respiratory distress. Subcutaneous emphysema, another classic finding, is present < 30% of the time. One important clinical clue is rapid development of pleural effusion (often within hours), usually on the left side. If left unrecognized, patients rapidly develop mediastinitis and septic shock. Initial chest x-ray usually shows mediastinal or free peritoneal air that can change within hours to subcutaneous emphysema and pleural effusion (as in this patient). Mediastinal air (eg, retrocardiac air shadow) can be overlooked at times or can be interpreted as hiatal hernia. The diagnosis of esophageal rupture requires a high index of suspicion (even though rare) since it is a life-threatening medical emergency. It is important to perform an emergency esophagogram with a water-soluble contrast (Gastrografin®) to document esophageal leak. This also helps the thoracic surgeon identify the anatomic location of the leak prior to any kind of intervention. esophagogram (Choice B) Given this patient's recent chemotherapy, pancytopenia is expected. Culture of the bone marrow aspirate is used for evaluation of fever of unknown origin. (Choice C) Left-sided pleural effusion is also seen with pancreatitis, but mediastinal air is not. (Choice D) Pleural fluid analysis in esophageal perforation shows a very acidic pH and high amylase levels. These are nonspecific and would delay the diagnosis. (Choice E) This patient is septic. Echocardiography would be of little value. Educational objective: Boerhaave syndrome (esophageal rupture) is a medical emergency. The classic triad of forceful vomiting, chest pain, and subcutaneous emphysema should alert the physician about its possibility. Chest x-ray may show mediastinal air and the diagnosis can be confirmed with an esophagram. Another important clinical clue is the rapid development of pleural effusion (often within hours), usually on the left side. __________ References: Boerhaave's syndrome after postoperative vomiting (http://www.ncbi.nlm.nih.gov/pubmed/15041618) Management of thoracic esophageal perforations. (http://www.ncbi.nlm.nih.gov/pubmed/21353582)

An 80-Year-Old Hospitalized Woman Is Evaluated for Chest Pressure and Dyspnea