|Year : 2017 | Volume
| Issue : 2 | Page : 271-273
Spontaneous esophageal rupture: A case of back pain
Luther K Fleury, Neal P Johnson, Michael I Silberman
Department of Emergency Medicine, University of Tennessee College of Medicine, Nashville; Emergency Medicine Residency Program, Saint Thomas - Rutherford Hospital, Murfreesboro, TN, USA
|Date of Web Publication||9-Jan-2018|
Dr. Michael I Silberman
1840 Medical Center Parkway, Suite 403, Murfreesboro, TN 37129
Source of Support: None, Conflict of Interest: None
Esophageal rupture is a rupture of the esophageal wall usually brought on by a sudden increase in intraluminal esophageal pressure. This disease is life threatening, and the mortality of patients is time dependent. We describe a case of an elderly woman who presented to the emergency department on 2 consecutive days, the 1st day with acute lumbar back pain and the 2nd day critically ill with altered mental status, hypotension, and shortness of breath. The patient was ultimately diagnosed with spontaneous esophageal perforation.
The following core competencies are addressed in this article: Practice-based learning and improvement, Medical knowledge, and Patient care.
Keywords: Back pain, esophageal perforation, hydropneumothorax
|How to cite this article:|
Fleury LK, Johnson NP, Silberman MI. Spontaneous esophageal rupture: A case of back pain. Int J Acad Med 2017;3:271-3
| Introduction|| |
Esophageal rupture is a difficult diagnosis and the mortality of patients is time dependent. With an incidence of 3.1/1,000,000 per year, esophageal ruptures are most commonly iatrogenic involving endoscopic procedures, and other causes are usually related to an increased intraluminal pressure.,, Approximately 15% of esophageal ruptures are spontaneous. This case report of spontaneous esophageal rupture varies from the usual presentation. We describe the case of an elderly woman who presented to the emergency department on 2 consecutive days, the 1st day with acute lumbar back pain and the 2nd day critically ill with altered mental status, hypotension, and shortness of breath. The patient was ultimately diagnosed with spontaneous esophageal perforation.
| Case Report|| |
A 71-year-old female presented to the emergency department with altered mental status and decreased responsiveness. The onset of symptoms was 4 h before her arrival. Her husband stated that she woke up with decreased activity and mild confusion. One hour before arrival, the husband recorded a blood pressure of 100/50 mmHg at home, which was accompanied by worsening mental status. The patient also complained of shortness of breath and fatigue but denied fever, vomiting, abdominal pain, or chest pain. In addition, the patient was seen the day before in the emergency department for lower back pain after standing up from the toilet, had negative imaging of the lumbar spine, and was sent home with hydrocodone and a diagnosis of lumbar back strain. The patient's husband noted that she had taken some of her hydrocodone pills for her back pain the morning before arrival.
On physical examination, the patient was afebrile, hypotensive with a blood pressure of 86/51 mmHg, heart rate of 98, and hypoxic at 89% through pulse oximetry on room air. She was awake and alert but appeared in distress. She had minimally reactive pinpoint pupils and was tachypneic at 28 breaths per minute, with diminished breath sounds in the right lung base. There was mild tenderness to palpation across her lower back. Peripheral pulses were equally bilaterally. Abdomen was nondistended and nontender. No subcutaneous emphysema was noted. Following initial evaluation, multiple doses totaling 2.4 mg of Narcan was administered to the patient without response. A chest computed tomography (CT) was immediately ordered. Laboratory work was notable for hemoglobin 16.4 g/dL, white blood cell 3.7 mm 3, BUN 31 mg/dL, creatinine 2.0 mg/dL, lactic acid 8.8 mmol/L, and glucose 127 mg/dL. Troponin, hepatic panel, brain natriuretic peptide, and electrocardiogram were unremarkable. The chest CT identified extraluminal paraesophageal gas with a large right hydropneumothorax and moderate effusion on the left [Figure 1] and [Figure 2]. Hyperdensity within the right hydropneumothorax suggested possible hemothorax or esophageal contents. There was a leftward shift of the mediastinum along with significant atelectasis of the right lung. The CT findings suggested a possible esophageal rupture.
|Figure 2: Axial view showing large right hydropneumothorax with extraluminal paraesophageal gas and moderate effusion on the left. Hyperdensity within the right hydropneumothorax suggests possible hemothorax or esophageal contents. Leftward shift of the mediastinum along with significant atelectasis of the right lung|
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A chest tube was inserted with a return of air and yellow-green gastric appearing contents. Thoracic surgery was consulted, and the patient underwent immediate esophageal repair. The patient was ultimately diagnosed with spontaneous esophageal perforation with mediastinal abscess.
| Discussion|| |
Spontaneous perforation of the esophagus is a rare, life-threatening medical condition. Esophageal ruptures are most commonly iatrogenic involving endoscopic procedures, and other causes of this disease are usually related to an increased intraluminal pressure., Boerhaave's syndrome (BS) is a subtype of this disease in which increased intraluminal pressure, generally from vomiting or retching, is the contributable cause., Precipitating factors for BS can also include straining and even laughing in sporadic cases., It is typically taught to be recognized by Mackler's triad, which consists of vomiting, chest pain, and subcutaneous emphysema. The diagnosis of BS is frequently missed or delayed due to lack of common or expected clinical signs and an ambiguous presentation.,
Mortality of patients with esophageal rupture is time dependent, and the most important prognostic factor is time between rupture and initiation of treatment. The mortality of esophageal rupture reaches 100% if treatment is not started within 48 h from presentation. Diagnosis is generally a clinical history, and physical examination that supports the disease combined with posterioranterior and lateral chest radiographs, with 90% of cases showing abnormal signs such as pleural effusion, pneumothorax, hydropneumothorax, pneumomediastinum, widening mediastinum, and subcutaneous emphysema., Chest X-ray performed immediately after an esophageal rupture may appear normal as pneumomediastinum can take 1 h to develop, and pleural effusion generally takes longer., A water-soluble contrast swallow study can be used to show leakage of contrast into the mediastinum or pleural cavity.
The management of esophageal rupture is dictated by the location of the rupture, the delay between perforation and treatment, the vitality of the esophageal wall, the severity and degree of mediastinitis, the condition of the patient, and the patient's age., The majority of cases require surgery although sporadic cases of successful medical management have been reported.
The patient in this case initially improved after a thoracotomy, esophageal repair, and treatment of septic shock. Eventually, her condition deteriorated with a prolonged hospital course. She developed a right lung empyema, profound thrombocytopenia, and jaundice. She required multiple additional surgeries including a lung decortication, esophageal stent, laparoscopic cholecystectomy, bilateral video-assisted thoracoscopic surgery, tracheostomy, and percutaneous endoscopic gastrostomy tube placement. Ultimately, she progressed to multiorgan failure and acute respiratory distress syndrome. On hospital day 28, she was placed on comfort care and ultimately expired.
Looking back at the patient's initial visit, other than having back pain after increased abdominal pressure (having a bowel movement), there were no pertinent findings in the history or clinical examination that may have suggested possible esophageal injury. There were no findings seen on lumbar X-ray, as they rarely expose above the diaphragm. Esophageal rupture, albeit an extremely difficult diagnosis, should be on the differential in patients complaining of pain, more specifically chest pain, after increased abdominal pressure.
| Conclusion|| |
Esophageal rupture is a life-threatening disease with a high morbidity and mortality and should be included in the differential diagnosis for any elderly patient complaining of back pain, particularly in those with any retching, vomiting, or straining before their pain. Although back pain is typically not emphasized, it may be beneficial to suspect an esophageal rupture in a patient with sudden chest, abdominal, or back pain even in the absence of vomiting or retching.
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Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The authors attest that this scholarly work was conducted in accordance with the recommendations of The International Committee of Medical Journal Editors. Patient consent was obtained prior to the submission of this manuscript for publication in the International Journal of Academic Medicine.
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[Figure 1], [Figure 2]