The most specific findings on CT include air around the distal esophagus and aorta, pleural effusions, esophageal wall thickening and pulmonary infiltrates.4 A fluoroscopic esophagram performed with water soluble contrast is the diagnostic procedure of choice in patients with suspected perforation of the esophagus. Dilute barium can be used if the water soluble contrast is not diagnostic.5 Findings on esophagram that are indicative of perforation include direct visualization of the submucosal tear or extravasation of contrast. 4 While visualization of the fistula or the actual tear is a definitive finding, there has been a =10% false-negative rate reported with esophagography.6 Helical CT esophagography using oral solution composed of 10% IV iodinated contrast material, effervescent granules and water has shown promising results for demonstrating esophageal extravasation.7 The treatment of choice consists of emergent primary surgical repair of the esophageal tear and removal of debris from the mediastinum.
R A D I O L O G I C A L C A S E Boerhaave’s syndrome Jeffrey M. Pollock, MD, Jeffrey C. Brandon MD, Margaret H. Mowry, MD, and Steven K. Teplick, MD CASE SUMMARY A 51-year-old woman presented to our emergency room with acute onset of left shoulder and epigastric pain. The pain followed an episode of choking and retching during a dinner at a steak- house. On physical exam her abdomen was tender to palpation most notably in the upper quadrants where she had guarding and rebound tenderness. Lab- oratory values were unremarkable. IMAGING FINDINGS FIGURE 1. Upright PA view of the chest show- FIGURE 2. CT of the Chest with contrast ing a double gastric bubble consistent with using lung windows shows mediastinal air A chest X-ray (Figure 1) showed free free intraperitoneal air. There was no evidence tracking between the esophagus and the air adjacent to the stomach bubble in the of pneumomediastinum or pleural effusion. aorta. left upper quadrant. A computed tomog- raphy (CT) scan (Figures 2 and 3) of the thoracotomy. A piece of brown tissue autopsy showed a tear in the distal chest, abdomen and pelvis, using intra- was removed from the mediastinum esophagus, emphysema and food in the venous and oral contrast, showed medi- and sent to pathology where it was mediastinum.1 astinal air adjacent to the descending found to be skeletal muscle consistent Esophageal rupture is likely sec- aorta. The CT scan also showed free with the piece of steak the patient ondary to a rapid rise in the intralumi- intraperitoneal air and a soft-tissue den- reported ingesting prior to the episode nal pressure of the distal esophagus sity adjacent to the distal esophagus of vomiting. The patient had an during emesis.2 (Figure 4). No contrast extravasation uncomplicated hospital course. Upper The syndrome can be a challenge for was seen on CT. Subsequently, barium GI examination 1 week post esoph- clinicians because the clinical presen- swallow showed an area of contrast ageal repair showed no evidence of tation rarely has the classic presenta- extravasation from the distal esophagus extravasation or stricture formation. tion of retrosternal chest pain 2.0 cm proximal to the gastroe- The patient was seen for routine following an episode of emesis with sophageal junction (Figure 5). screening mammography 2 years later associated emphysema. Patients may and was asymptomatic. have symptoms that can mimic DIAGNOSIS Boerhaave’s syndrome was origi- myocardial infarction, sepsis, pancre- Boerhaave’s syndrome nally described by Hermann Boer- atitis or aortic dissection. Additionally, haave in 1724. The first report was the the patients may present with hypoten- DISCUSSION case of Bar
Pages to are hidden for
"Boerhaave's syndrome"Please download to view full document