A 65-year-old woman comes to the office due to feeling her heart race, even while she is at rest. She has had multiple episodes like this over the past 2 weeks, lasting anywhere from a few minutes to a couple of hours and associated with lightheadedness. The patient's other medical conditions include obesity, type 2 diabetes mellitus, hypertension, and gastroesophageal reflux disease. She smoked a pack of cigarettes daily from age 16 to 35. Vital signs are normal except for an irregularly irregular pulse. The patient is diagnosed with atrial fibrillation and given anticoagulation and rate control medication. In preparation for cardioversion, she undergoes transesophageal echocardiography, which rules out a mural thrombus. That evening, the patient develops severe chest and interscapular back pain. Temperature is 38.9 C (102 F), blood pressure is 100/70 mm Hg, and pulse is 108/min. The patient is in distress and restless. Heart and lung sounds are normal. ECG shows sinus tachycardia without ST segment changes. Chest x-ray reveals a widened mediastinum. Stool testing for occult blood is negative. Which of the following is the best next step to diagnose this patient's condition?

Question

A 65-year-old woman comes to the office due to feeling her heart race, even while she is at rest.  She has had multiple episodes like this over the past 2 weeks, lasting anywhere from a few minutes to a couple of hours and associated with lightheadedness.  The patient's other medical conditions include obesity, type 2 diabetes mellitus, hypertension, and gastroesophageal reflux disease.  She smoked a pack of cigarettes daily from age 16 to 35.  Vital signs are normal except for an irregularly irregular pulse.  The patient is diagnosed with atrial fibrillation and given anticoagulation and rate control medication.  In preparation for cardioversion, she undergoes transesophageal echocardiography, which rules out a mural thrombus.  That evening, the patient develops severe chest and interscapular back pain.  Temperature is 38.9 C (102 F), blood pressure is 100/70 mm Hg, and pulse is 108/min.  The patient is in distress and restless.  Heart and lung sounds are normal.  ECG shows sinus tachycardia without ST segment changes.  Chest x-ray reveals a widened mediastinum.  Stool testing for occult blood is negative.  Which of the following is the best next step to diagnose this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d8ee_ad3b_bc81_bf1ac0edf580_MD0003_00 This patient who underwent esophageal instrumentation (eg, transesophageal echocardiography [TEE]) now has severe chest pain, fever, and a widened mediastinum on chest x-ray, concerning for esophageal perforation. Esophageal perforation is most often due to instrumentation; endoscopy, particularly when performed with additional interventions (eg, biopsy, cauterization, stricture dilation), is a common cause. Patients may develop severe chest pain (and/or back pain due to the esophagus's posterior anatomical location) and systemic findings (eg, fever) within hours of the procedure. A minority have crepitus (subcutaneous emphysema) or crunching heard on auscultation (Hamman sign). Chest x-ray may reveal findings consistent with air/fluid leakage into the mediastinum (eg, pneumomediastinum, widened mediastinum) or thorax (eg, pneumothorax, pleural effusion). Visualization of contrast leaking from the esophagus into surrounding tissues confirms the diagnosis, by either esophagography or CT scan using water-soluble contrast. Barium contrast is more sensitive but can incite a granulomatous inflammatory response; it is used when water-soluble contrast esophagography is inconclusive. Esophageal perforation is a life-threatening condition. Therefore, management includes emergent surgical consultation, in addition to intravenous antibiotics and proton pump inhibitors. Surgical debridement and repair remain the mainstay of treatment, although select healthy patients (eg, limited leak, minimal symptoms, no signs of sepsis) may receive a trial of medical management. (Choice A) Severe chest pain in the setting of multiple risk factors for coronary artery disease (eg, type 2 diabetes, hypertension, smoking) is concerning for acute coronary syndrome. However, interscapular back pain and fever are less likely, and this patient's ECG shows no ischemic changes. (Choices B and C) Severe chest pain radiating to the back and widened mediastinum on chest x-ray are concerning for aortic dissection, which CT angiogram of the chest and TEE can both diagnose. However, aortic dissection often has other associated findings (eg, new aortic regurgitation murmur, asymmetric blood pressure), and this patient's fever and recent instrumentation make esophageal perforation a much more likely diagnosis. (Choice D) Upper gastroesophageal endoscopy is often used to evaluate for sources of upper gastrointestinal bleeding (unlikely given this patient's negative stool occult blood test). It could likely visualize the esophageal injury in this patient but is not used for initial diagnosis of esophageal perforation because air insufflation and instrumentation may worsen the injury. Educational objective: Esophageal perforation is a life-threatening complication of esophageal instrumentation. Clinical presentation may include severe chest/back pain, fever, and a widened mediastinum on chest x-ray. Water-soluble contrast esophagography can confirm the diagnosis. 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 65-Year-Old Woman Comes to the Office Due to Feeling