A 50-year-old lady presented to the emergency room with severe left-sided chest pain following an episode of forceful vomiting. A history of giddiness was present. Her past medical and surgical history were insignificant. On examination, she was having a respiratory rate of 24/min and her blood pressure was 100/60 mmHg. She was diaphoretic and surgical emphysema was present. On plain radiography, hydropneumothorax was present. Gastrograffin study of the patient was performed Figure 1.
Figure 1.
Gastrograffin study
QUESTIONS
Q1. What is the diagnosis?
Q2. What is the classical presentation of this condition?
Q3. What are the characteristics of pleural fluid in this condition?
Q4. Which are the factors that decide the line of management in this condition?
Q5. What are the indications for conservative line of management in this condition?
ANSWERS
A1. Gastrograffin study revealed leak of the contrast into the left posterolateral aspect of pleural cavity, which indicates perforation in the esophagus. This condition is known as Boerhaave syndrome.
A2. A classical presentation of this condition is Mackler triad: vomiting, subcutaneous emphysema, and lower thoracic pain.
A3. The characteristics of pleural fluid include a pH of <6, undigested food particles, and a high amylase content.[1]
A4. Location of perforation, etiology, and time interval between injury and diagnosis are the factors that decide the line of management.[2]
A5. Indications for conservative management include the following:[3] absence of clinical signs of infection, perforation that drains back into the esophagus, and contained perforation within the thoracic cavity.
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
REFERENCES
- 1.Drury M, Anderson W, Heffner JE. Diagnostic value of pleural fluid cytology in occult Boerhaave’s syndrome. Chest. 1992;102:976–8. doi: 10.1378/chest.102.3.976. [DOI] [PubMed] [Google Scholar]
- 2.Brewer LA, Carter R, Mulder GA, Stiles QR. Options in the management of perforations of the esophagus. Am J Surg. 1986;152:62–9. doi: 10.1016/0002-9610(86)90144-3. [DOI] [PubMed] [Google Scholar]
- 3.Shaffer HA, Jr, Valenzuela G, Mittal RK. Esophageal perforation. A reassessment of the criteria for choosing medical or surgical therapy. Arch Intern Med. 1992;152:757–61. doi: 10.1001/archinte.152.4.757. [DOI] [PubMed] [Google Scholar]