An elderly male comes to the ED with worsening epigastric and retrosternal chest pain, nausea, and forceful vomiting after eating some spicy food and consuming a small amount of alcohol with dinner. 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?
A) aspiration pneumonitis
B) erosive esophagitis
C) esophageal perforation
D) mallory-weiss syndrome
E) perforated gastric ulcer
The answer is (c). Vomiting + bleeding = mallory-weiss, but vomiting + PAIN + L pleural effusion = Boerhaave’s. Boerhaave’s can lead to mediastinitis (from gastric contents entering sterile sites) and lead to a left pleural effusion with accompanied pneumomediastinum. Fever can take >4 hours to develop. Mortality from mediastinis can double if not properly treated within 24 hours of diagnosis. Make sure to start broad spectrum antibiotics and obtain an emergent thoracic surgery consult!
Why L sided pleural effusion?
The mid esophagus lies next to the right pleura while the lower esophagus abuts the left pleura. Rupture occurs most commonly in the left posterolateral wall of the distal third of the esophagus with extension into the left pleural cavity.