A 24-year-old primigravid woman at 10 weeks gestation comes to the emergency department with severe nausea and vomiting. During the past 3 weeks, the patient has had nausea lasting most of the day with occasional emesis, but over the past day her vomiting has become so severe that she has been unable to keep down any fluids. Her medical history includes obesity and appendectomy. Temperature is 36.7 C (98 F), blood pressure is 90/50 mm Hg, pulse is 116/min, and respirations are 16/min. The patient is clutching an emesis basin, into which she frequently spits. On physical examination, mucous membranes are dry and skin turgor is decreased. Heart and breath sounds are normal, and the abdomen is soft and nontender. Transvaginal ultrasound shows a viable, intrauterine twin pregnancy. She is admitted to the hospital for intravenous fluids and antiemetics. Although her emesis subsides, 4 hours later she reports worsening chest discomfort that radiates to her back. Blood pressure is 102/66 mm Hg, and pulse is 112/min. Breath sounds are equal, and a retrosternal crunching sound is heard with each heartbeat. The abdomen is soft but mildly tender in the epigastrium. Which of the following is the most likely diagnosis in this patient?

Question

A 24-year-old primigravid woman at 10 weeks gestation comes to the emergency department with severe nausea and vomiting.  During the past 3 weeks, the patient has had nausea lasting most of the day with occasional emesis, but over the past day her vomiting has become so severe that she has been unable to keep down any fluids.  Her medical history includes obesity and appendectomy.  Temperature is 36.7 C (98 F), blood pressure is 90/50 mm Hg, pulse is 116/min, and respirations are 16/min.  The patient is clutching an emesis basin, into which she frequently spits.  On physical examination, mucous membranes are dry and skin turgor is decreased.  Heart and breath sounds are normal, and the abdomen is soft and nontender.  Transvaginal ultrasound shows a viable, intrauterine twin pregnancy.  She is admitted to the hospital for intravenous fluids and antiemetics.  Although her emesis subsides, 4 hours later she reports worsening chest discomfort that radiates to her back.  Blood pressure is 102/66 mm Hg, and pulse is 112/min.  Breath sounds are equal, and a retrosternal crunching sound is heard with each heartbeat.  The abdomen is soft but mildly tender in the epigastrium.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d1a4_8690_bc81_6394fe227397_MD0003_00 This patient with hyperemesis gravidarum and protracted vomiting now has chest pain radiating to the back and a retrosternal crunching sound, concerning for esophageal perforation (EP). Repeated vomiting episodes, particularly when the patient resists the vomiting reflex, can cause effort rupture of the esophagus (Boerhaave syndrome). Efflux of air into the mediastinum (pneumomediastinum) through the full-thickness esophageal tear can cause a crunching sound heard in the precordium with each heartbeat (Hamman sign) or neck/precordial crepitus (subcutaneous emphysema). Retrosternal chest pain radiating to the back is common; other manifestations of EP include odynophagia, dyspnea, and sepsis (eg, fever, tachycardia). EP is a surgical emergency because spillage of esophageal contents can lead to mediastinitis, septic shock, and death. Diagnosis can be confirmed by esophagography or CT scan with water-soluble contrast, with visualization of contrast leaking from the esophagus into surrounding tissues. Surgical debridement and repair are the mainstay of treatment, with adjunctive restriction of oral intake and administration of broad-spectrum antibiotics and proton pump inhibitors. (Choices A and C) Gallbladder hypomotility during pregnancy and obesity increase this patient's risk of gallstones; however, biliary colic causes postprandial epigastric/right upper quadrant pain. Gallstone pancreatitis causes rapid-onset, severe epigastric (rather than chest) pain radiating to the back but is typically accompanied by (rather than preceded by) nausea/vomiting. Neither condition causes pneumomediastinum (Hamman sign). Mild epigastric tenderness can be seen with EP, possibly due to local inflammation. (Choice B) Aspiration of inflammatory gastric acid can occur with protracted vomiting and incite pneumonitis. This can cause chest pain but would typically present with abrupt-onset respiratory distress, cyanosis, and infiltrates on chest x-ray. Diffuse lung field crackles rather than retrosternal crunching would be expected. (Choice E) In contrast to Boerhaave syndrome, Mallory-Weiss syndrome represents a partial-thickness (mucosal) esophageal tear. Although it can occur with repeated vomiting, it most commonly presents as hematemesis and would not cause pneumomediastinum (which indicates full-thickness perforation). (Choice F) Gastroesophageal reflux is common in pregnant women due to decreased lower esophageal sphincter tone and increased intraabdominal pressure from uterine enlargement. Gastric acid reflux can cause esophagitis and chest pain. However, it typically presents more chronically with postprandial heartburn, odynophagia, or dysphagia. Although severe esophagitis is a risk factor for perforation, reflux esophagitis alone does not cause pneumomediastinum. Educational objective: Protracted vomiting can cause esophageal rupture (Boerhaave syndrome). Patients typically have severe chest/back pain and may have pneumomediastinum with crepitus or a precordial crunching sound on auscultation (Hamman sign). Esophageal perforation is a surgical emergency. References: Esophageal perforation. (http://www.ncbi.nlm.nih.gov/pubmed/24267495) Pneumomediastinum following esophageal rupture associated with hyperemesis gravidarum. (http://www.ncbi.nlm.nih.gov/pubmed/12214835)

A 24-Year-Old Primigravid Woman at 10 Weeks Gestation Comes to the Emergency