Clinical Reasoning with Dr. Mohindra: Esophageal Rupture

On Wednesday, we went over an interesting case of esophageal rupture with Dr. Vibha Mohindra. She took us through the case step by step, letting us hear her differential and how different pieces of data changed how she viewed the case and prompted her to ask different questions.

Our patient was an elderly gentleman with a history of diabetes, hypertension, and osteoarthritis on chronic NSAIDs who presented with days of progressive, nonspecific chest pain. Shortly after presentation, he had an episode of hematemesis and subsequently experienced rapid respiratory and hemodynamic decompensation, requiring emergency intubation, high doses of multiple vasopressors, and broad spectrum antibiotics. Subsequent imaging revealed a large left pleural effusion, which was found to be a Candida empyema after chest tube placement. Fungal empyemas are most commonly a postoperative complication of cardiothoracic surgery, but also occur in esophageal rupture. Interestingly, this patient’s pleural cytology later showed thick proteinaceous material intermixed with inflammatory cells and vegetable material. Gastrograffin swallow study revealed extravasation of constrast outside of the GI tract into the left pleural space and mediastinum, confirming a distal esophageal perforation. Cardiothoracic surgery was consulted for repair.

Esophageal perforation is an extremely rare, but potentially fatal diagnosis. 15% of esophageal perforations are considered spontaneous (Boerhaave’s syndrome). The following is our illness script for Esophageal rupture:

Epidemiology:

  • VERY rare (3 cases per million per year)
  • 15% of those are spontaneous (Boerhaave’s)

Signs/symptoms:

  • Excruciating retrosternal chest pain
  • Odynophagia, dyspnea, and sepsis
  • Crepitus on palpation of the chest wall
  • Hamman’s sign (mediastinal crackling with each heartbeat esp in left lateral decub position)

Diagnosis: 

  • Established by contrast esophogram (gastrograffin is first line given its water solubility, barium causes a mediastinitis)
  • Clues:
    • CXR: mediastinal widening, mediastinal air, hydropneumothorax.
    • Pleural fluid with undigested food, elevated salivary amylase level, and pH <6

Treatment:

  • Strict NPO
  • IV broad spectrum abx
  • IV PPI
  • Drainage of fluid collections and debridement of necrotic tissue if present.
  • Surgical repair.
  • After recovery, EGD with esophageal biopsies should be performed to find any underlying pathology (malignancy, eosinophilic esophagitis, etc)

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