A 19-year-old college student is brought to the emergency department by his friends due to severe retrosternal and upper abdominal pain. The patient was out with his friends drinking alcohol and celebrating the end of final exam week. An hour before arrival, he had several episodes of emesis, which is when he began experiencing the pain. He has had no medical issues other than ankle sprains while playing basketball. The patient has smoked cigarettes on several occasions and drinks alcohol on the weekends. His father died of a myocardial infarction at the age of 45. Temperature is 38.3 C (101 F), blood pressure is 95/56 mm Hg, pulse is 120/min, and respirations are 30/min. Pulse oximetry is 97% on room air. Height is 201 cm (6 ft 7 in), and weight is 90 kg (198.4 lb). On physical examination, the patient appears intoxicated and diaphoretic. Oral mucous membranes are dry, and there is no pharyngeal erythema. Cervical lymph nodes are not enlarged, but there is palpable crepitus in the suprasternal notch. Lung auscultation reveals bilateral symmetric breath sounds. Heart sounds are normal. There is mild epigastric tenderness without guarding or rebound. There is no extremity edema or cyanosis. Which of the following is the most likely cause of this patient's current condition?

Question

A 19-year-old college student is brought to the emergency department by his friends due to severe retrosternal and upper abdominal pain.  The patient was out with his friends drinking alcohol and celebrating the end of final exam week.  An hour before arrival, he had several episodes of emesis, which is when he began experiencing the pain.  He has had no medical issues other than ankle sprains while playing basketball.  The patient has smoked cigarettes on several occasions and drinks alcohol on the weekends.  His father died of a myocardial infarction at the age of 45.  Temperature is 38.3 C (101 F), blood pressure is 95/56 mm Hg, pulse is 120/min, and respirations are 30/min.  Pulse oximetry is 97% on room air.  Height is 201 cm (6 ft 7 in), and weight is 90 kg (198.4 lb).  On physical examination, the patient appears intoxicated and diaphoretic.  Oral mucous membranes are dry, and there is no pharyngeal erythema.  Cervical lymph nodes are not enlarged, but there is palpable crepitus in the suprasternal notch.  Lung auscultation reveals bilateral symmetric breath sounds.  Heart sounds are normal.  There is mild epigastric tenderness without guarding or rebound.  There is no extremity edema or cyanosis.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d1a3_9c2f_bc81_0328ce204ff9_MD0003_00 This patient with retrosternal pain, fever, and crepitus in the setting of protracted vomiting likely has a full thickness rupture of the esophagus (esophageal perforation). Forceful retching may increase intraesophageal pressure enough to cause a full-thickness effort rupture of the esophagus (Boerhaave syndrome), which may allow efflux of esophageal fluid and air into the mediastinum. The leaked gastrointestinal contents cause severe chest/abdominal pain and a systemic inflammatory response (eg, fever, tachycardia) that can quickly progress to septic shock and death; the leaked air (pneumomediastinum) may be palpated as suprasternal crepitus (subcutaneous emphysema). These features distinguish esophageal perforation from Mallory-Weiss syndrome, which can be due to a similar etiology (eg, retching) but leads only to a partial-thickness tear classically associated with hematemesis (from submucosal plexus bleeding) (Choice E). Visualization of contrast extravasating from the esophagus into surrounding tissues, either by esophagography or CT scan with water-soluble contrast (barium is more inflammatory), confirms the diagnosis of esophageal perforation. Intravenous broad-spectrum antibiotics and proton pump inhibitors should be administered, all oral intake restricted, and emergent surgical consultation obtained. Most perforations will require operative debridement and repair. (Choice A) This patient's upper abdominal pain in the setting of heavy alcohol consumption is concerning for acute pancreatitis. However, acute pancreatitis does not cause suprasternal crepitus and-except in severe cases (eg, multiorgan failure)-is not typically associated with fever. (Choice B) Aortic dissection should always be considered with acute-onset, severe chest pain, especially if risk factors are present (eg, Marfan syndrome in a tall, thin patient). However, crepitus and fever in the setting of protracted vomiting make esophageal perforation much more likely. (Choice C) Aspiration of inflammatory gastric acid can occur with protracted vomiting, potentially inciting pneumonitis. This can cause chest pain and fever but would typically present as abrupt-onset respiratory distress with diffuse lung field crackles (due to inflammatory edema) on auscultation. It would not cause crepitus. (Choice F) Primary spontaneous pneumothorax can occur in tall, thin young men from rupture of a subpleural bleb. Pneumothorax might cause dyspnea and subcutaneous emphysema, but decreased breath sounds would be expected on the affected side. Fever is uncommon. Educational objective: Effort rupture of the esophagus (Boerhaave syndrome) can occur with vomiting. Leakage of esophageal air through the full-thickness perforation may cause pneumomediastinum, evidenced by suprasternal crepitus on examination. Confirmation with esophagography or CT scan using water-soluble contrast should prompt emergent surgical consultation. References: Esophageal perforation. (http://www.ncbi.nlm.nih.gov/pubmed/24267495) Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. (http://www.ncbi.nlm.nih.gov/pubmed/22035338)

A 19-Year-Old College Student Is Brought to the Emergency Department