Critical Care: Student/Resident Case Report Poster - Critical Care III |

Tension Hydropneumothorax: A Rare Consequence of Esophageal Necrosis With Boerhaave Syndrome FREE TO VIEW

Michelle Lieu, BS; Michael Layoun, MD; Darren Pan, BS; William Davis, BS; David Dai, MD; Guy Soo Hoo, MD; Jaime Betancourt, MD
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UCLA-West Los Angeles VA Healthcare Center, Los Angeles, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):415A. doi:10.1016/j.chest.2016.08.428
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Boerhaave syndrome, the spontaneous transmural rupture of the esophagus, is an rare condition with an estimated mortality of 20-40%. Diagnosis is often delayed due to a combination of nonspecific symptoms and mimicry of other emergent conditions. We describe a case of Boerhaave syndrome due to acute necrotizing esophagitis in a patient presenting with tension hydropneumothorax.

CASE PRESENTATION: 65 yo male with a history of hepatitis C, alcoholism and prior small bowel obstruction (SBO) related to abdominal surgery was admitted to our hospital following 3 days of abdominal pain and emesis attributed to a partial SBO. The admission chest film (CXR) was unremarkable except for minor basilar atelectasis. On hospital day 2, he developed acute chest pain with ischemic EKG changes. Cardiac cath revealed no evidence of obstructive coronary artery disease. Post procedure, he developed excruciating chest pain radiating to his back associated with tachycardia, hypotension and absent breath sounds over the left lung. CXR demonstrated interval opacification of the left hemithorax with mediastinal shift. An emergent needle thoracostomy produced air and dark fluid containing food debris, followed by tube thoracostomy which drained 4 liters of bilious, enteric output. Chest CT demonstrated a large left hydropneumothorax with free air around the esophagus. EGD demonstrated a circumferential area of “black esophagus” in the distal third of the esophagus consistent with necrosis and perforation. The patient underwent emergent esophagectomy with cervical esophagostomy, diagnostic laparotomy, and gastrostomy tube placement. His post-operative course was complicated by hypoxemic respiratory failure, ischemic stroke, and gastrointestinal hemorrhage on hospital day 21 leading to cardiac arrest and death.

DISCUSSION: This is the first reported case of tension hydropneumothorax as a consequence of esophageal rupture from acute esophageal necrosis in the literature. A high index of clinical suspicion is necessary to diagnose esophageal rupture as the presenting symptoms of dyspnea, chest pain, nausea and vomiting are non-specific. Chest imaging may demonstrate mediastinal widening, mediastinal free air and/or a pleural effusion. Boerhaave syndrome may occur in patients with a normal esophagus or in those with underlying esophageal pathology such as malignancy, chronic esophagitis, or in this case acute esophageal necrosis from a presumed ischemic etiology. Aggressive surgical or endoscopic therapy is warranted in most patients.

CONCLUSIONS: Boerhaave syndrome should be considered in the differential diagnosis of chest pain, especially in the setting of nausea and vomiting, and with this case, as a non-procedural, non-pulmonary cause of tension hydropneumothorax.

Reference #1: de Schipper JP, Pull ter Gunne AF, Oostvogel HJ, van Laarhoven CJ. Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Dig Surg. 2009. 26(1):1-6.

DISCLOSURE: The following authors have nothing to disclose: Michelle Lieu, Michael Layoun, Darren Pan, William Davis, David Dai, Guy Soo Hoo, Jaime Betancourt

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