A 64-year-old man comes to the emergency department with sudden onset of epigastric abdominal pain and vomiting. He attended a colleague's retirement party the night before and admits that he had "a little too much to drink." The patient vomited twice when he got home and noticed abdominal pain after the second vomiting episode. He thought the pain was related to "heartburn" and took extra-strength calcium carbonate antacids with little relief. He tried to sleep, but the severe pain kept him awake. The patient has a history of hypertension and takes amlodipine. He is a current smoker with a 40-pack-year history.
His temperature is 38.0° C (100.4° F), blood pressure is 108/64 mm Hg, pulse is 110/min, and respirations are 18/min. Pulse oximetry is 96% on room air. Examination shows a man in moderate distress. There are normal first and second heart sounds. Decreased breath sounds are heard on the left lower lung field with dullness to percussion. There is both right upper-quadrant and epigastric tenderness without rebound or guarding.
Chest x-ray reveals pneumomediastinum and a moderate-sized left pleural effusion.
Which of the following is the best next step in managing this patient?

Question

A 64-year-old man comes to the emergency department with sudden onset of epigastric abdominal pain and vomiting.  He attended a colleague's retirement party the night before and admits that he had "a little too much to drink."  The patient vomited twice when he got home and noticed abdominal pain after the second vomiting episode.  He thought the pain was related to "heartburn" and took extra-strength calcium carbonate antacids with little relief.  He tried to sleep, but the severe pain kept him awake.  The patient has a history of hypertension and takes amlodipine.  He is a current smoker with a 40-pack-year history.
His temperature is 38.0° C (100.4° F), blood pressure is 108/64 mm Hg, pulse is 110/min, and respirations are 18/min.  Pulse oximetry is 96% on room air.  Examination shows a man in moderate distress.  There are normal first and second heart sounds.  Decreased breath sounds are heard on the left lower lung field with dullness to percussion.  There is both right upper-quadrant and epigastric tenderness without rebound or guarding.
Chest x-ray reveals pneumomediastinum and a moderate-sized left pleural effusion.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_960f_d403_853d_d9c8bc610f3f_MD0002_00 This patient's presentation suggests spontaneous esophageal rupture (SER). SER (Boerhaave syndrome) is usually due to prolonged nausea and vomiting causing an acute rise of intraesophageal pressure combined with negative intrathoracic pressure. This leads to a transmural esophageal tear and acute barotrauma with esophageal air/fluid leaking into surrounding areas (eg, mediastinum, pleura). Although it is a rare diagnosis, SER has a 20% mortality rate, usually due to infectious complications (eg, empyema, mediastinitis, septic shock). Patients usually present with vomiting/retching and chest/upper abdominal pain with rapid progression to odynophagia, fever, dyspnea, and septic shock. Physical examination may show subcutaneous emphysema but is not a sensitive finding. Chest x-ray may reveal pneumomediastinum or pleural effusions. Pleural fluid analysis is typically exudative with low pH and very high amylase (> 2500 IU). Computed tomography or contrast esophagography with Gastrografin is preferred for confirming the diagnosis. (Choice A) Abdominal ultrasound is used to examine the internal organs of the abdomen but would not be as sensitive in evaluating for suspected esophageal rupture in this patient. (Choice B) Chest tube placement would clear the pleural effusion but would not address the underlying serious perforation. (Choice D) Esophagogastroduodenoscopy (EGD) with insufflation of air can extend the perforation and introduce air into the mediastinum. However, when done under a controlled setting in the operating room, EGD may be useful for select patients to directly visualize the perforation and plan treatment. (Choice E) A high pleural fluid amylase can occur in acute pancreatitis, chronic pancreatitis with pleural effusion, and esophageal rupture. Serum amylase is high in acute pancreatitis, which is not usually associated with pneumomediastinum, as seen in this patient. Educational objective: Spontaneous esophageal rupture is due to acute barotrauma from vomiting or retching that leads to a transmural tear. Patients classically present with forceful retching followed by severe retrosternal chest and upper abdominal pain. Diagnosis is confirmed with computed tomography or esophagography with gastrografin. __________ References: Boerhaave syndrome: a diagnostic conundrum. (http://www.ncbi.nlm.nih.gov/pubmed/21686835) Evolving options in the management of esophageal perforation. (http://www.ncbi.nlm.nih.gov/pubmed/15063302)

A 64-Year-Old Man Comes to the Emergency Department with Sudden