SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: We present an initially unrecognized Boerhaave syndrome complicated further by nasogastric tube placement.
CASE PRESENTATION: An 88 year old male presented to our hospital with acute right upper quadrant abdominal pain radiating to back and one episode of vomiting. He denied cough, chest pain, dyspnea or melena. Past medical history included sick sinus syndrome, diverticulosis and hiatal hernia. In ER, patient was noted to have temperature of 100.6 F and was in mild respiratory distress. He had decreased breath sounds bilaterally, right upper quadrant tenderness without guarding and heme-negative rectal exam. Laboratory studies including liver function tests were unremarkable. Chest radiograph showed bibasilar opacities with trace bilateral pleural effusions and Computed Tomography (CT) scan of abdomen revealed a markedly distended stomach and a moderate sized hiatal hernia, but no acute findings. The patient was admitted for suspected community acquired pneumonia. Given an unclear history of hemetamesis, a nasogastric tube was placed and dark heme-positive gastric aspirate was obtained. However, patient became confused and restless thereafter and the tube was removed. Over the course of the day, patient developed worsening fever and hypotension requiring intravenous fluid resuscitation and became more hypoxic with increasing oxygen requirements. A repeat chest radiograph revealed increased lucency in the right hemithorax extending superiorly into cervical soft tissues concerning for pneumomediastinum. CT scan confirmed the diagnosis of an extensive pneumomediastinum and revealed a moderate pneumopericardium. Left lateral wall of the hiatal hernia was ill-defined with heterogenous attenuation, suggestive of distal esophageal or hiatal hernia rupture. To further characterize the lesion, gastrograffin esophagogram was performed which showed rapid dispersion of contrast in lower mediastinum but no discrete lesion. Meanwhile, patient clinically deteriorated further. The family declined any surgical interventions and patient passed away soon after.
DISCUSSION: Boerhaave syndrome or spontaneous nontraumatic esophageal rupture, is an uncommon gastrointestinal emergency with high mortality. A variable clinical presentation, vague physical exam findings and an often nonspecific initial chest radiograph leads to delay in diagnosis. Once diagnosed by gastrograffin esophagogram, it requires immediate surgical intervention to be compatible with life.
CONCLUSIONS: Boerhaave syndrome should be considered in the differential of an acute presentation of chest or abdominal pain with vomiting to facilitate early diagnosis and management.
1) Schwartz JA, Turnbull TL, Dymowski J, Uehara DT. Boerhaave's syndrome: an elusive diagnosis. Am J Emerg Med. 1986 Nov;4(6):532-6.
2) Jagminas L, Silverman RA. Boerhaave's syndrome presenting with abdominal pain and right hydropneumothorax. Am J Emerg Med. 1996 Jan;14(1):53-6.
DISCLOSURE: The following authors have nothing to disclose: Anuja Vyas, Kriti Lonial, Dhwanil Vyas
No Product/Research Disclosure InformationUniversity of Connecticut, Farmington, CT