Case of Hydropneumothorax Following Multiple Episodes of Vomiting

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SESSION TITLE: Cardiothoracic Disorders SESSION TYPE: Case Report Slide PRESENTED ON: Saturday, April 16, 2016 at 04:00 PM - 05:00 PM INTRODUCTION: Boerhaave’s syndrome1 first described by Hermann Boerhaave in 1724 and by Barret in 1946. It is the most serious and rapidly fatal perforation of gastrointestinal tract. Classical presentation of a patient with this syndrome is vomiting, chest pain, and subcutaneous emphysema (Mackler’s triad); however, this classical triad is rare to found. Unusual presentation with variety of features makes it challenge to diagnose. CASE PRESENTATION: A 52 year male presented with respiratory distress, left side chest pain, and fever for six days. All these symptoms proceeded by 5 episodes of vomiting. A chest x-ray done by some other physician, which revealed left side pleural effusion about 300 ml fluid was aspirated, but there was no improvement in symptoms. At this time we received patient in our hospital. Patient was dyspnoeic with a respiratory rate of 38 breaths/min, pulse of 114 beats/min, and blood pressure of 130/74 mmHg. Clubbing, cyanosis, lymphadenopathy, or subcutaneous emphysema were absent. Chest examination revealed findings suggestive of left hydropneumothorax. A provisional diagnosis of left hydropneumothorax (iatrogenic) was made. Initial investigations haemoglobin of 10.8 mg/dL, total leucocyte count 14,600/mm3 with 75% neutrophils. Serum electrolytes, blood urea, liver function test and electrocardiogram were with in normal limits. chest x-ray showed a left sided hydropneumothorax. The patient was put on oxygen, and broad-spectrum antibiotics. A contrast enhanced computed tomography (CECT) scan and barium swallow was done. CECT showed a left sided hydropneumothorax and pneumomediastinum. Barium study showed a leakage of contrast to the mediastinum. Patient was immediately shifted to Cardio Thoracic Surgery for operative intervention. DISCUSSION: Boerhaave’s syndrome is the spontaneous transmural rupture of lower oesophagus. In the lower part of oesophagus there is lack of striated muscle and the vertical arrangement of longitudinal muscles, so there is a structural weakness in this part. Conditions like vomiting, childbirth, heavy weight lifting may cause increase in intra oesophageal pressure and results in spontaneous rupture of lower part of oesophagus. clasical Mackler’s triad is rare to found. So this condition is often miss diagnosed. Emergency operative intervention is the treatment of choice in most patients with Boerhaave’s syndrome. Thoracotomy with primary repair of the oesophageal rupture along with drainage of the pleural cavity and mediastinum is recommended if diagnosis is made within 24 hours of onset of symptoms2. The technique of bypassing of oesophagus along with feeding jejunostomy is recommended in patients who present late. CONCLUSIONS: This was a case of left side hydropneumothorax with pneumomediastinum secondary to oesophageal rupture (Boerhaave’s syndrome). Reference #1: Barret NR. Spontaneous perforation of the oesophagus: Thorax 1946;1:48-54. Reference #2: Hutter JA, Fenn A, Braimbridge MV. Br J Surg 1985;72:208-9. DISCLOSURE: The following authors have nothing to disclose: Mohit Bhatia, J. K. Samaria, Anand Bansal No Product/Research Disclosure Information