A CASE OF SPONTANEOUS ESOPHAGEAL PERFORATION PRESENTING AS A RIGHT-SIDED PLEURAL EFFUSION

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous esophageal perforation or Boerhaave's syndrome is characterized by rupture of the esophagus due to the rapid and spontaneous rise in intraluminal esophageal pressure. Only 14% of patients present with Meckler's triad, which includes severe vomiting, chest pain and subcutaneous emphysema. Approximately 90% of the perforations occur at the left lateral aspect of the distal esophagus, causing a left-sided pleural effusion. This case report describes an 85-year-old man who presented with Boerhaave's syndrome due to a right-sided effusion. CASE PRESENTATION: An 85-year-old male presented to the emergency department with 2 weeks of progressively worsening dyspnea, abdominal pain, nausea and vomiting. He denied a history of heavy lifting, chest trauma, alcohol or tobacco use. He was initially afebrile and hemodynamically stable. Jugular veins were not distended. Breath sounds were decreased on the right. There was no murmur and abdomen was soft nontender. ACS workup was negative. Subsequent CT scan revealed hydropneumothorax, subtle pneumomediastinum, and free intraperitoneal air. A chest tube was placed due to interval development of tachycardia & hypotension. Pleural fluid analysis yielded pH 4.23, WBC 2734, glucose 157, LDH <55, protein 2.0, amylase <26, and bilirubin <0.1. Gastrographin swallow demonstrated extravasation of contrast medium through a distal defect in the esophagus. Esophagogastroduodenoscopy showed esophageal perforation from 30 cm to 42 cm extending through the gastroesophageal junction into the cardia of the stomach with a dusky, friable, ischemic appearing distal esophageal mucosa. Rather than placing an esophageal stent as originally planned, the procedure was converted to an open esophagectomy with percutaneous endoscopic gastrostomy placement. His immediate postoperative course was largely uneventful and he was extubated post-op day 2. He was successfully discharged a few weeks later. DISCUSSION: This case is notable for a pleural fluid analysis which yielded a pH of 4.23. While pleural fluid pH is dependent on many factors and may be falsely low due to the presence of local anesthetic or heparin, exposure to air, or time delay, a pH of 4.23 in the setting of dyspnea, vomiting, and pneumomediastinum should raise concern for Boerhaave's syndrome. Another unique aspect of this case was the location of the pleural effusion. Nearly 90% of perforations are left-sided due to anatomical weakness in the left lateral aspect of the distal esophagus causing left-sided pleural effusions. This patient atypically presented with a right-sided pleural effusion. Prior literature indicates that this presentation contributes to a delay in diagnosis and subsequent increase in mortality. CONCLUSIONS: In the case presented here, vomiting, right-sided pleural effusion, and careful pleural fluid analysis aided in making the correct diagnosis and led to prompt surgical treatment. REFERENCE #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462217/ REFERENCE #2: https://www.ncbi.nlm.nih.gov/books/NBK430808/ REFERENCE #3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153269/ DISCLOSURES: No relevant relationships by Matthew Bernens, source=Web Response No relevant relationships by Kari McCoy, source=Web Response No relevant relationships by Caroline Mears, source=Web Response No relevant relationships by David Pierce, source=Web Response