Teaching Case

Sudden onset of shortness of breath, pleuritic chest pain and angor anima.

The patient presented with sudden onset of shortness of breath, pleuritic chest pain and angor anima. PA chest radiograph was performed (figure 1a) with a further examination following placement of a left chest drain (figure 2a). The chest drain unfortunately fell out, but his shortness of breath had improved. Following the re-insertion of chest drain his shortness of breath improved. Clarification of the presenting history revealed an initial history of severe central chest pain following ingestion of food and alcohol. Hence a water-soluble oesophagogram was performed (figure3).
The first chest radiograph demonstrated a large left pleural effusion, moderate left pneumothorax and pneumomediastinum (figure 1b), after insertion of chest drain there was a reduction in the size of the left pleural effusion and partial resolution of the pneumothorax (figure 2b). Oesophagogram revealed an oesophageal rupture with contrast passing into the left pleural space initially and then via the chest drain tract to the skin surface.

The above finding and history are consistent with spontaneous oesophageal rupture (Boerhaave’s syndrome).
Spontaneous oesophageal rupture often occurs following large ingestion of alcohol and food, other causes for oesophageal rupture include intrinsic oesophageal lesion such as neoplasm or ulcer, trauma, endoscopic perforation, or post-anaesthetic vomiting. No matter the cause for oesophageal rupture mortality doubles every 6 hours being greater than 85% at 24 hours. In spontaneous rupture classically the patient will have had vomiting, severe chest pain, and surgical emphysema, often clinically they will be in shock and be short of breath. On chest radiograph they often have surgical emphysema, pneumomediastum, a left sided pleural effusion or pneumothorax and basal lung atelectasis. The findings in the initial chest radiograph are highly suggestive for an oesophageal leak or perforation.
The intensity and character of the central chest pain is so severe that it can be difficult to distinguish from aortic dissection, myocardial infarction or peptic ulceration. Currently the most appropriate imaging investigation to distinguish between these (apart from an acute MI) would be a thoraco-abdominal CT examination following intravenous and oral contrast media. CT can illustrate the plain radiographic finding of oesophageal rupture in more detail with, in addition, identification of the site rupture and the adjacent peri-oesophageal air tracks.
As the oesophagogram was confirmatory of oesophageal rupture our patient went onto receive an emergency operative repair rather than undergo further radiological investigation. However an oesophagogram may miss 20-30% of oesophageal leaks and hence CT as described above may represent the best initial radiological assessment.
Late complications following oesophageal rupture and reparative surgery include mediastinitis and abscess formation. The main differential diagnosis for pneumomediastum include in addition to oesophageal rupture, tracheal trauma, severe asthma and barotrauma.