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. The patient continues to have chest pain that radiates to the back and worsens during deep breaths. He appears restless and dyspneic. Blood pressure is now 110/60 mm Hg and pulse is 130/min. Intravenous fluids are administered. Laboratory results are as follows:
Which of the following is the most appropriate test for confirming this patient's diagnosis?

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. The patient continues to have chest pain that radiates to the back and worsens during deep breaths.  He appears restless and dyspneic.  Blood pressure is now 110/60 mm Hg and pulse is 130/min.  Intravenous fluids are administered.  Laboratory results are as follows:
 Which of the following is the most appropriate test for confirming this patient's diagnosis?

Quizplus · Accepted Answer

Explanation: The best initial diagnostic test for esophageal perforation is an esophagogram with water-soluble contrast (eg, diatrizoate). This test provides a definitive diagnosis in 90% of cases. If the test is negative but clinical suspicion is high, barium contrast can be used. Water-soluble contrast is preferred as barium can produce further mediastinal irritation and injury in patients with Boerhaave syndrome. (Choice B) CT scan of the chest, not the abdomen, can be of value if the diagnosis is unclear after esophagogram or if the patient cannot tolerate the procedure. However, it is not the test of choice as it may fail to detect small tears. (Choice C) Esophageal manometry and pH studies are useful in patients with symptoms of gastroesophageal reflux disease (GERD) unresponsive to therapy with proton pump inhibitors. GERD typically presents with a sensation of heartburn with occasional dysphagia or regurgitation, not hematemesis, fevers, and hemodynamic instability. (Choice D) Lateral soft tissue neck radiography may be able to detect subcutaneous air or a soft tissue defect associated with a proximal esophageal tear, but the patient has evidence of a distal tear with a pleural effusion. Regardless, x-ray is a poorly sensitive technique for diagnosing Boerhaave syndrome. (Choice E) Upper gastrointestinal endoscopy is used to evaluate hematemesis due to a variety of causes, but is generally avoided in patients in whom Boerhaave syndrome is suspected as it can worsen pneumomediastinum due to insufflation of the esophagus prior to passing the scope. It should be reserved for patients who require esophageal repair but are unable to tolerate surgery. Educational objective: The best diagnostic test for esophageal perforation is an esophagogram with water-soluble contrast. CT scan of the chest is helpful but may not detect small tears or ruptures. Upper gastrointestinal endoscopy may worsen pneumomediastinum and should generally be avoided in patients with suspected Boerhaave syndrome. References: Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours. (http://www.ncbi.nlm.nih.gov/pubmed/22035338)

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