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Weekly Chest CasesCases by Disease Category

Case No : 1174 Date 2020-04-21

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  • Courtesy of Ki-Nam Lee, Eun-Ju Kang, Sanghun Baek / Dong-A University Medical Center, Dong-A University College of Medicine
  • Age/Sex 56 / M
  • Chief ComplaintVomiting followed by acute onset chest pain
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Spontaneous esophageal perforation (Boerhaave syndrome)
Radiologic Findings
Fig 1. Chest AP shows diffuse subcutaneous emphysema. Linear air-strands are noted from the mediastinum to the neck and pericardial border. Bilateral pleural effusion and pneumothorax are noted. Both lungs show diffuse ground-glass opacity.
Fig 2-4. CT scans viewed at lung window settings show abnormal air collection detected in the posterior mediastinum and pericardial space indicating pneumomediastinum and pneumopericardium, surrounding the collapsed mid esophagus and diffuse subcutaneous emphysema.
Fig 5. CT scan viewed at mediastinal window setting shows focal esophageal wall defects above the esophagogastric junction indicating full-thickness esophageal perforation and bilateral pleural effusion.

Figs 6. Gastrografin esophagography shows contrast leakage on 4cm above the EG junction.

Brief Review
Spontaneous esophageal perforation (Boerhaave syndrome) is a very uncommon, life-threatening surgical emergency that should be suspected in all patients presenting with lower thoracic-epigastric pain and a combination of gastrointestinal and respiratory symptoms. Variable clinical manifestations and subtle or unspecific radiographic findings often result in critical diagnostic delays. Multidetector computed tomography complemented with CT-esophagography represents the ideal one-stop shop investigation technique to allow a rapid, comprehensive diagnosis of Boerhaave syndrome, including identification of suggestive periesophageal abnormalities, direct visualization of esophageal perforation and quantification of mediastinitis.
Whatever its location and etiology, rupture of the esophagus is a life-threatening condition which remains a difficult diagnostic and management problem. If esophageal perforation is detected within the first 24 h of the onset of symptoms, surgical treatment is usually possible. After 24 h the survival rate is 20% or lower. Pathophysiologically, Boerhaaves syndrome is due to a sudden rise in intraluminal esophageal pressure during vomiting, in the presence of a closed glottis. There is failure of the cricopharyngeous muscle to relax due to neuromuscular incoordination. Age is an important prerequisite factor for this neuromuscular incoordination. Anatomically the tear is located at the left posterolateral wall in the lower third of the esophagus (in the chest). Free fluid and air leak into the posterior mediastinum and then into the left pleural cavity. Fluoroscopic esophagography with ingestion of water-soluble contrast medium was used to confirm suspected esophageal perforation through the direct demonstration of extraluminal contrast extravasation.
Please refer to
Case 582, Case 658, Case 1053,
References
1. Teh E, Edwards J, Duffy J, Beggs D. Boerhaave's syndrome: A review of management and outcome. Interact Cardiovasc Thorac Surg. 2007;6:640
Keywords
esophagus, esophageal perforation, pneumomediastinum,

No. of Applicants : 88

▶ Correct Answer : 85/88,  96.6%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - , Japan HIROAKI ARAKAWA
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Niigata University , Japan ATSUSHI UEHARA
  • - TWMU Medical Center East , Japan MASAFUMI KAIUME
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - consultant radiologist , India ALISHA
  • - , Korea (South) HYEYOUNG CHOI
  • - CH de la Cote Basque , France PAUL ARDILOUZE
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Lille , France BENOIST CAPON
  • - IRSA LA ROCHELLE , France JEAN LUC BIGOT
  • - The University of Tokyo Hospital , Japan MOTO NAKAYA
  • - Ondokuz Mayis University , Turkey CETIN CELENK
  • - , Japan SHIN-ICHI CHO
  • - Kyeongpook National University Hospital , Korea (South) CHANGGUN KIM
  • - Samsung Medical Center , Korea (South) CHOHEE KIM
  • - Chonnam National University Hwasun Hospital , Korea (South) HONG SEOK CHOI
  • - Asan Medical Center , Korea (South) EUNJI CHOI
  • - Hospital de Braga , Portugal MARCIO RODRIGUES
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - , Senegal AXEL MBUYU KAYEMBE
  • - Scans world , India PHILSON JOSEPH MUKKADA
  • - DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
  • - , Korea (South) JIN YOUNG LEE
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Asan Medical Center , Korea (South) YURA AHN
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Hamamatsu University Hospital , Japan HAYATO NOZAWA
  • - Other , Korea (South) SANG HYUP HONG
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - Hanyang University Hospital , Korea (South) HYEJIN PARK
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - , France JEAN-MICHEL COULLET
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Konkuk University Medical Center , Korea (South) JI HEE KANG
  • - The Catholic University of Korea Seoul St. Mary , Korea (South) HYUNJIN KIM
  • - Chungbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Chonbuk National University Hospital , Korea (South) YOUNGKWANG LEE
  • - , Korea (South) CHAEHUN LIM
  • - Soonchunhyang University Hospital Bucheon , Korea (South) SEONGHWAN BYUN
  • - University of Tsukuba Hospital , Japan HIROAKI TAKAHASHI
  • - Seoul Veterans Hospital , Korea (South) JI HOON NOH
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Other , Korea (South) MINSU KIM
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - Okayama Red Cross General Hospital , Japan SOICHIRO OKAMOTO
  • - Seoul Veterans Hospital , Korea (South) JANG SEONG WON
  • - Columbia asia refferal hospital,Bengaluru , India PRAVIN KUMAR M
  • - Escola Paulista de Medicina , Brazil RENATO MASSON DE ALMEIDA PRADO
  • - TB centre kasaragod. , India rikhy krishnan
  • - , Australia RIO BUENO
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - Kitano Hospital , Japan SATOSHI IKEDA
  • - , Korea (South) SUNGEUN YUN
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Nishida Hospital , Japan SHOJI OKUDA
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - , India SHYJUMON GEORGE
  • - Rohini Hospital , India SIBI S
  • - Other , Korea (South) JEONGHYUN LEE
  • - Chonbuk National University Hospital , Korea (South) MINJEE KIM
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
  • - , India SUSHANT JOSHI
  • - , Japan KAZUMA TERAUCHI
  • - Tokyo Metropolitan Bokutoh Hospital , Japan TOMOKI WADA
  • - Private sector , Greece VASILIOS TZILAS
  • - , Japan YUMI MAEHARA
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - Chonnam National University Hwasun Hospital , Korea (South) WONGI JEONG
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - , Korea (South) HYUNGYU LEE
  • - Asan Medical Center , Korea (South) HYEMIN AHN
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Semi-Correct Answer : 1/88,  1.1%
  • - Beaulieu clinic Geneva , Switzerland GILLES GENIN
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