Review Question - QID 213420

This patient likely has Boerhaave syndrome as demonstrated by his severe chest pain and positive CT findings in the setting of prolonged emesis. Patients with the condition may have crepitus on palpation of the chest due to subcutaneous emphysema.

Boerhaave syndrome is a medical emergency characterized by a transmural, usually distal esophageal rupture with pneumomediastinum. It results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure (e.g., severe straining or vomiting). The condition usually occurs in patients with a normal underlying esophagus. Patients often present with sudden, excruciating retrosternal chest pain with a history of severe retching and vomiting. Physical examination may demonstrate crepitus and Hamman sign (mediastinal crackling with heartbeat upon auscultation). Diagnosis is confirmed via imaging (e.g., CT, radiograph, or water-soluble contrast esophagram). Management is dependent on the severity of the rupture and may include both medical and/or surgical treatments.

Figure/Illustration A is a CT image of the chest demonstrating air surrounding the esophagus (arrowhead) and extraluminal contrast (arrow) suggestive of esophageal perforation.

Incorrect Answers:
Answer 2: Diminished breath sounds can be seen in cases of pneumothorax where the air is present within the pleural space. Although patients may complain of chest pain, the CT findings in this patient are suggestive of Boerhaave syndrome.

Answer 3: Friction rub is a finding commonly found in patients with pericarditis. The chest pain in pericarditis is rarely sudden and severe like the one seen in this patient.

Answer 4: Pulsus paradoxus is a characteristic finding in cardiac tamponade, severe asthma, and severe chronic obstructive pulmonary disease (COPD). This patient’s history and medical history do not suggest these diseases.

Answer 5: Unequal blood pressure in both arms suggests aortic dissection, which can also present with sudden, severe chest pain. This patient’s medical history of hypertension also makes this diagnosis more likely. However, this patient’s imaging finding suggests Boerhaave syndrome.

Bullet Summary:
Crepitus on palpation of the chest is a physical examination finding suggestive of Boerhaave syndrome.