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

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