Diagnosis
Comments
Myocardial infarction
Chest pain, more on the left side, left arm and jaw pain, diaphoresis, ST segment elevation, and elevated troponins
Pericarditis
Substernal, pleuritic chest pain, worse supine, better leaning forward, fever, tachycardia, friction rub, pulsus paradoxus
Pneumothorax
Chest pain, shortness of breath, tachycardia, decreased/absent breath sounds on the affected side
Pneumonia
Shortness of breath, fever, fatigue, productive cough, and decreased breath sounds on the affected side
Aortic dissection
Shearing or tearing chest pain radiating to upper back, shortness of breath, differences in blood pressure in arms, impending doom, severe HTN, history of Marfan’s
Peptic ulcer disease
Post-prandial epigastric abdominal pain, nausea, vomiting, bloating
Acute pancreatitis
Epigastric pain radiating to the back, nausea, vomiting, anorexia, cholelithiasis, alcohol abuse, elevation of amylase/lipase
Mallory-Weiss tear
Forceful vomiting and retching, followed by UGI bleed, typically in alcoholic or bulimic patients; often resolves spontaneously
Boerhaave’s syndrome
Forceful vomiting and retching, followed by chest pain and sepsis typically in alcoholic or bulimic patients; crepitus with palpation around the sternum
Watch Out
Boerhaave’s syndrome has high mortality if not recognized and treated in a timely fashion. The mortality rate is significantly greater in those that have a delay in diagnosis beyond 24 hours.
What Is the Most Likely Diagnosis?
In a patient presenting with chest pain after forceful vomiting (retching) accompanied by crepitus with palpation around the sternum, a left-sided pleural effusion, and evidence of systemic inflammatory response syndrome (fever, tachycardia, leukocytosis with a left shift), the most likely diagnosis is Boerhaave’s syndrome, a type of spontaneous esophageal rupture.
History and Physical
What Are the Risk Factors for Boerhaave’s Syndrome?
Patients at greatest risk are alcoholics. Binge drinking places patients at risk of forceful vomiting/retching. It can also occur in patients who overeat, which results in aggressive vomiting. It most commonly occurs in males 50–70 years old.
Why Is Boerhaave’s Syndrome So Often Unrecognized?
There is a robust differential for a patient who presents with chest pain. Since its manifestations mimic so many other diseases, esophageal perforation often goes unsuspected or misdiagnosed.
What Is Mackler’s Triad?
The principal symptoms include sudden lower thoracic pain, sometimes radiating to the back and aggravated by swallowing. Mackler’s triad (vomiting, thoracic pain, and subcutaneous emphysema) is highly suggestive of the diagnosis of Boerhaave’s syndrome. All three parts of the triad are found in less than one third of cases, which often leads to a delay in diagnosis. The clinical signs most often observed, in decreasing order of frequency, are vomiting (84 %), thoracic pain (79 %), dyspnea (53 %), epigastric pain (47 %), and dysphagia (21 %).
What Is the Most Specific Sign of an Esophageal Rupture?
Subcutaneous emphysema after forceful retching is pathognomonic for esophageal rupture. This is identified on physical exam by crepitus with palpation around the sternum. Unfortunately, this finding is not very sensitive, as it is seen in only 27 % of patients.
How Does Boerhaave’s Syndrome Differ from Mallory-Weiss?
Boerhaave’s syndrome | Mallory-Weiss | |
|---|---|---|
Population | Alcoholics/bulimics after forceful vomiting | Alcoholic/bulimics after forceful vomiting |
Pathophysiology | Full-thickness rupture of the esophagus secondary to increased intragastric pressure | Partial tear of mucosa at gastroesophageal junction, secondary to increased intragastric pressure |
Presentation | Thoracic pain radiating to back, left-sided pleural effusion, signs of sepsis | Upper GI bleed |
Natural course | Can progress to sepsis and death; most often will require immediate surgical repair and drainage | Most resolve spontaneously; surgery rarely indicated |
Pathophysiology
What Are the Most Common Causes of Esophageal Perforation?
An esophageal perforation is a rare incident that often constitutes a surgical emergency. Despite improvements in detection and management, esophageal perforation remains a highly fatal disease with mortality rates reported as high as 40 %. The majority of perforations (approximately 60 %) are the result of an iatrogenic injury with upper endoscopy perforation being the most common cause. Other causes may include blunt or penetrating trauma, foreign body ingestion, or a perforating malignancy. The final 10–20 % of perforations account for “spontaneous” ruptures, also known as Boerhaave’s syndrome. Forceful vomiting causes a dramatic rise in intragastric pressure which is transmitted to the esophagus in the presence of a relaxed lower esophageal sphincter. If such a rise in pressure within the esophagus occurs in conjunction with a failure of relaxation of the cricopharyngeus muscle, then tremendous pressures are transmitted to the esophageal wall, leading to perforation.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
