HPI

• 71 yo male is boarding in the ED after an admission for a RLE DVT
• On day 2 of his hospital admission, he has several episodes of emesis
• He begins complaining of chest pain, and vital signs reflect new hypotension, tachycardia and hypoxia

Exam

T: 99.9  HR 124  BP 74/42 RR 30 Pox 88% on RA

• Appearance: Ill appearing, tachypneic, in distress, clutching chest
• Heart: Tachycardic
• Lungs: Diminished breath sounds on the left
• Abdomen: soft, NTND
• Extremities: cool with intact distal pulses, erythema and edema of RLE known to have DVT

Diagnostics

• ECG: Sinus tachycardia, no ST/T wave abnormalities
• CXR:

CXR interpretation: L sided pleural effusion

Management

• Intubtated and started on broad spectrum antibiotics
• Started on vasopresors for worsening hypotension with MAPs in the 40s 
• A left sided chest tube was placed which drains ~5 liters of dark brown-black liquid which appears identical to orogastric tube drainage
• A STAT portable xray after instillation of oral contrast via OG tube into esophagus shows distal esophageal contrast leak confirming suspected diagnosis of esophageal perforation 

Outcome and Teaching Pearls

• Cardiothoracic surgery evaluated pt but he was determined to not be a surgical candidate
• GI performed endocscopy demonstrating a large 4cm full thickness perforation of the distal esophagus with freely visible contaminated mediastinum
• An esophageal stent is inserted
• Pt continues to decompensate and ultimately dies
• Esophageal perforation from forceful vomiting (i.e. Boerhaave's syndrome) or instrumentation is a medical and surgical emergency
• Presents with sudden onset severe, unrelenting, sharp retrosternal chest pain and hemodynamic instability, including hypotension, tachycardia, and tachypnea rapidly leading to shock
• Hamman's Crunch/Hamman's sign: a sign of pneumomediastinum, a crunching sound on cardiac auscultation
• Chest Xray often demonstrates pleural effusion (from the leakage of GI content), pneumothoraxes (usually on the left, as in this case), and pneumomediastinum. 
• A CT scan with water soluble oral contrast (Gastrografin) or an endoscopy will make the diagnosis
• Treatment: early broad spectrum antibiotics and operative management 
• Without operative intervention, the mortality is 100%

Source

Soreide J and Vista A. Esophageal perforation: diagnostic work-up and clinical decion-making in the first 24 hours. Scand J Trauma Resusc Emerg Med: 2011; 19:66/