A 54-year-old man comes to the emergency department due to worsening epigastric and retrosternal chest pain, nausea, and vomiting. The patient started having severe nausea, retching, and forceful vomiting after eating some spicy food and consuming a small amount of alcohol with dinner several hours ago. The vomitus contained ingested food particles, but the most recent episode included a small amount of bright red blood. The pain has progressively worsened, and he now has pain while swallowing and mild shortness of breath. The patient has had dyspeptic symptoms in the past, which he self-treated with over-the-counter antacids. He does not use tobacco or illicit drugs. He appears pale, diaphoretic, and in moderate distress. Temperature is 38 C (100.4 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 24/min. Neck veins are flat. Dullness to percussion and decreased breath sounds are present over the left basal area. Abdominal examination reveals epigastric tenderness and decreased bowel sounds. Stool occult blood is positive. Upright chest x-ray reveals a small pleural effusion of the left lung, and ECG shows sinus tachycardia; the imaging results are otherwise unremarkable.
Which of the following is the most likely cause of this patient's current condition?

Question

A 54-year-old man comes to the emergency department due to worsening epigastric and retrosternal chest pain, nausea, and vomiting.  The patient started having severe nausea, retching, and forceful vomiting after eating some spicy food and consuming a small amount of alcohol with dinner several hours ago.  The vomitus contained ingested food particles, but the most recent episode included a small amount of bright red blood.  The pain has progressively worsened, and he now has pain while swallowing and mild shortness of breath.  The patient has had dyspeptic symptoms in the past, which he self-treated with over-the-counter antacids.  He does not use tobacco or illicit drugs.  He appears pale, diaphoretic, and in moderate distress.  Temperature is 38 C (100.4 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 24/min.  Neck veins are flat.  Dullness to percussion and decreased breath sounds are present over the left basal area.  Abdominal examination reveals epigastric tenderness and decreased bowel sounds.  Stool occult blood is positive.  Upright chest x-ray reveals a small pleural effusion of the left lung, and ECG shows sinus tachycardia; the imaging results are otherwise unremarkable.
Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c153_fd49_8f63_c5f304dc0e1f_MD0005_00 This patient's presentation with retrosternal chest pain after repeated episodes of vomiting is classic for spontaneous esophageal perforation (Boerhaave syndrome) complicated by acute mediastinitis. Other associated symptoms are dyspnea, odynophagia, epigastric pain, and shoulder pain. Boerhaave syndrome is characterized by a full-thickness tear of the esophagus due to sudden elevation in esophageal pressure (eg, vomiting) allowing gastric contents to enter previously sterile sites, in this case the mediastinum (resulting in mediastinitis). Most tears occur in the distal third of the esophagus, and the negative intrathoracic pressure within the chest results in an influx of esophageal contents into the pleural cavity, causing inflammation and pleural effusion (typically on the left). The effusion can be accompanied by pneumomediastinum (free air within the chest), pneumothorax, or both. Fever due to mediastinitis often takes >4 hours to develop, which can delay diagnosis. Urgent management is needed as mediastinitis carries a high mortality rate that doubles if it is not properly treated within 24 hours of diagnosis. In contrast to Boerhaave syndrome, a Mallory-Weiss tear is a mucosal (ie, partial thickness) tear of the esophagus. A Mallory-Weiss tear can also present with hematemesis following nausea and vomiting; however, perforation does not occur, so fever, chest pain, mediastinitis, left pleural effusion (which is due to fluid leakage), and hemodynamic instability would be unlikely (Choice D). (Choice A) Aspiration pneumonitis can be seen after episodes of vomiting; however, it most commonly occurs during emesis in patients with a decreased level of consciousness or an inability to protect the airway. This patient has not described changes in mental status, and pleural effusion or gastrointestinal bleeding would not be expected in aspiration pneumonitis. (Choice B) Erosive esophagitis is frequently caused by direct esophageal injury due to medication ingestion. Common offenders include bisphosphonates and tetracyclines. Typical presentation is with burning chest pain, but the fever and clinical instability associated with Boerhaave syndrome are not expected in erosive esophagitis. (Choice E) Perforated gastric ulcers are another surgical emergency causing marked hemodynamic instability; however, acute-onset, severe abdominal pain is expected, and upright chest x-ray often reveals free air under the diaphragm. In addition, gastric ulcers are not associated with repetitive vomiting. Educational objective: Esophageal perforation, also known as Boerhaave syndrome, usually presents as acute retrosternal chest pain following episodes of repeated vomiting. Most tears occur in the distal third of the esophagus and are associated with left-sided pleural effusion. Pneumomediastinum and/or pneumothorax can occur as well. A delay in surgical management is associated with mediastinitis and a high mortality rate. References: Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial. (http://www.ncbi.nlm.nih.gov/pubmed/25589955)

A 54-Year-Old Man Comes to the Emergency Department Due to Worsening