Clinical Image 22: The Stuck Sub

WELCOME BACK TO ANOTHER CLINICAL IMAGE FROM THE CASE FILES OF THE BROWN EM RESIDENCY!

Case:

HPI: A 27 year-old male with no significant past medical history presents to the ED with chest pain. The patient states about 30 minutes prior to arrival he was eating a meatball sub and got the feeling “like something was stuck in my chest”. He drank water in an attempt to push the food into his stomach but it did not help.  He then tried to self induce vomiting multiple times when he developed acute chest pain. Over the course of several minutes his chest pain worsened and was now associated with shortness of breath, nausea and dry heaving, dysphagia, and odynophagia. He also feels as though his voice sounds hoarse.  He denies dizziness, syncope, palpitations, or abdominal pain. He’s been otherwise well leading up to this.   

Vitals: T: 99.4 BP: 138/68 P: 86 R: 16 SpO2: 100% on room air

Physical examination: Patient found sitting up in the stretcher and appears extremely uncomfortable. He is cool and clammy. He has diminished breath sounds bilaterally. He is noted to have right facial and neck swelling as well as underlying crepitus. Heart sounds are regular rate and rhythm without murmur, rub, or gallop. He has no abdominal tenderness, guarding, rebound, or distention. No other pertinent exam findings.

Chest X-ray imaging was obtained:

 Figure 1: Chest x-ray imaging on patient arrival

Figure 1: Chest x-ray imaging on patient arrival

What does the chest x-ray show and what is the presumptive diagnosis?

Pneumomediastinum concerning for esophageal rupture (Boerhaave’s Syndrome)

In the chest x-ray above we can see air tracking along the mediastinum (red arrows), as well as extensive subcutaneous emphysema tracking into the neck (green arrows).

 Figure 2: Pneumomediastinum. Air can be seen tracking along the mediastinum (red arrows), and into the subcutaneous tissues of the neck (green arrows).

Figure 2: Pneumomediastinum. Air can be seen tracking along the mediastinum (red arrows), and into the subcutaneous tissues of the neck (green arrows).

The patient’s respiratory distress worsened and he became hypoxic requiring oxygen by NRB. Repeat chest x-ray demonstrated a left sided pneumothorax, as identified by a pleural line (arrows).

 Figure 3: Left sided pneumothorax as identified by a pleural line (arrows)

Figure 3: Left sided pneumothorax as identified by a pleural line (arrows)

Some quick facts about Boerhaave’s Syndrome:

  • Full thickness perforation of the esophagus after a sudden increase in intraesophageal pressure, typically in the setting of forceful emesis.
  • Foreign body ingestion and food impaction may also result in perforation either directly or indirectly (forceful vomiting).
  • Blunt or penetrating neck trauma can also cause perforation, as well as instrumentation (endoscopy).
  • Most perforations are left sided and distal, although proximal perforations are more commonly seen with instrumentation.
  • Classic presentation is sudden onset, severe chest pain following forceful emesis. It often radiates into the back, abdomen, neck, and shoulders.
  • Patients are typically ill appearing, diaphoretic, dyspneic, and/or tachycardic.
  • On examination patients may have subcutaneous crepitus appreciated in the chest and neck. Hamman’s crunch, an audible crepitus appreciated on heart auscultation, is sometimes heard in the setting of pneumomediastinum.
  • Chest x-ray imaging may reveal pneumomediastinum, pneumoperitoneum, pneumothorax, subcutaneous air, or pleural effusions (typically left sided), although a normal x-ray does not rule out the diagnosis as mediastinal emphysema takes time to develop.
  • Patients can develop mediastinitis, pneumonitis, or peritonitis from the leakage of esophageal contents, which can rapidly develop into septic shock.
  • ED management includes resuscitation in the setting of septic shock, administration of broad spectrum antibiotics (consider anti-fungals as well), and surgical consultation.
  • Delay in diagnosis and treatment > 24 hours is associated with an increased rate in mortality.
  • Definitive management ranges from conservative for smaller tears with a more indolent clinical course, to surgical management for more severe perforations.

Pneumomediastinum versus Pneumopericardium: Does the distinction matter?  

Of course! The main importance is that pneumopericardium can develop tension physiology, whereas as pneumomediastinum typically does not. With pneumomediastinum, in addition to air tracking along the mediastinum, you can also see a pleural edge along the upper heart border. In this case, the pleural reflection is very thin, versus pneumopericardium in which there is a much thicker edge given the thickness of the pericardium. In pneumopericardium the air is confined to the pericardial space, where in pneumomediastinum it often decompresses into the subcutaneous tissue.

Case Conclusion:

Our patient underwent a left sided chest tube insertion for management of his pneumothorax followed by barium swallow to assess the severity of his perforation. He was found to have a small, focal, contained perforation in the distal esophagus.

 Figure 4: Barium swallow demonstrating distal esophageal perforation (arrows).

Figure 4: Barium swallow demonstrating distal esophageal perforation (arrows).

He received broad spectrum antibiotics and was admitted to the cardiothoracic surgery service where he underwent successful conservative management.

Faculty Reviewers: Dr. Alyson McGregor and Dr. Robert Tubbs

More Reading:

https://lifeinthefastlane.com/pulmonary-puzzle-003/

https://radiopaedia.org/articles/pneumomediastinum

https://radiopaedia.org/articles/pneumothorax

References:

1: Gorrochategui, M., et. al. Pneumothorax. Radiopaedia. 2017 <https://radiopaedia.org/articles/pneumothorax>.

2: Gorrochategui, M., et. al. Pneumomediastinum. Radiopaedia. 2017. <https://radiopaedia.org/articles/pneumomediastinum>.

3: Raymond, D., Jones, C. Surgical Management of Esophageal Perforation. UptoDate. 2017.

4: Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 328; 511-512.