S3420 Boerhaave's Syndrome Secondary to Tetrahydrocannabinol Use: A Case Report

Abstract

INTRODUCTION: Boerhaave syndrome is a rare, but often fatal and underdiagnosed condition. It is due to a sudden increase in intra-esophageal pressure combined with negative intrathoracic pressure resulting in a longitudinal esophageal perforation. CASE DESCRIPTION/METHODS: 24-year-old female with history of cannabis abuse presented to the emergency department with recurrent episodes of non-bloody, non-bilious vomiting. Symptoms started one week after discontinuing Tetrahydrocannabinol (THC). She complained of non-radiating epigastric pain associated with retching. Physical examination was significant for extensive subcutaneous crepitus around anterolateral area of neck and the upper chest with tenderness on epigastrium, without signs of peritoneal irritation. Laboratory tests were significant for hypokalemia and acute kidney injury. Chest radiography revealed subcutaneous emphysema on the neck and upper chest and a right lower lobe pneumothorax. Chest and abdomen computed tomography (CT) confirmed pneumomediastinum and pneumopericardium with air in the soft tissue circumferentially from the neck to the soft tissues of the upper chest wall. Gastrografin esophagram ruled out any evidence of extravasation of contrast from the esophagus consistent with a contained esophageal perforation. Decision was made to manage conservatively and follow up modified barium swallow confirmed no leaking from the esophagus. DISCUSSION: Complications associated with esophageal perforation include mediastinal inflammation, pneumothorax, pericardial tamponade, infected pericardial effusions and pneumomediastinum. Mackler's triad of vomiting, chest pain and subcutaneous emphysema is appreciated in 50% of cases. Hamman's sign of mediastinal “crackling” accompanying every heart beat heard best in the left lateral decubitus position may also be present. Imaging modalities for diagnosis include chest X-ray, esophagram, chest CT or endoscopy. 3 levels of management include conservative, endoscopic, and surgical. Decision is based on timing of symptoms, extent of injury and presence of sepsis. Timely management can substantially decrease morbidity and mortality. Differential diagnosis should be considered in cases with excessive THC use presenting with a combination of respiratory and gastrointestinal symptoms and confirmed with imaging. Despite the gastrografin swallow study not showing extravasation, this case was a classic presentation of a contained esophageal rupture, complicated by pneumomediastinum and pneumopericardium.