(P56) Esophageal Perforation: When Chest Pain Is Not Cardiac

Chief Complaint : Chest pain, back pain, and non-exertional dyspnea

History of Present Illness : A 92 year old female with a past medical history of Hypertension, Diabetes Type 2 (HbA1C 10.9%), and Osteoporosis was brought in by her son to the ED for sudden onset chest pain radiating to the mid-back, dyspnea, and fatigue x 1 day. Per son, the patient had been lying in bed more often with decreased energy x 1 week. No history of nausea, vomiting, cough, hemoptysis, diaphoresis, leg pain or swelling. No similar symptoms in the past. No travel, trauma, sick contacts, recent illness.

Pertinent Physical Exam: Upon initial arrival to the emergency department, elderly female noted in no acute distress. Cardiovascular exam with regular rhythm and tachycardia. Mild increased work of breathing and subcostal retractions. Lungs clear to auscultation. Abdomen soft, nondistended, and nontender. No lower extremity edema or tenderness. VS with tachycardia to 120s, Afebrile, and blood pressure within normal limits. Oxygen saturation 89% on room air, with 97% on 2 liters of nasal cannula.

Pertinent Laboratory Data: Initial laboratory investigations with WBC 21K. Trop 0.01, and CK 47. UCx with >100,000 CFU/mL E Coli. VBG with pH 7.36/pCO251/LA 4.0. Repeat VBG with pH 7.23/pCO2 69.9/LA 7.5. Repeat ABG with pH 7.16/ pCO2 61/LA 8.6. BMP: Na 125, Cr 0.84, Glucose 332. Anion Gap 17, Repeat BMP with Na 123, Bicarb 13, Cr 1.4, Glucose 534, Gap 24.

Case Discussion: 92 year old female presenting with sudden onset atraumatic chest pain radiating to the back. The patient was hypoxic and tachycardic on arrival. Laboratory testing with leukocytosis and lactic acidosis. CT Chest with small right and moderate-to-large left pleural effusions, left lower and upper lobe atelectasis, posterior right lower lobe atelectasis, extensive pneumomediastinum and soft tissue air, small left pneumothorax. Cardiothoracic surgery was consulted. Repeat CT chest with oral contrast demonstrating mid-esophageal perforation with increased left hydropneumothorax. Upon return from CT, patient became hemodynamically unstable on 15L non-rebreather mask. Diffuse crepitus appreciated. Patient was intubated and central access was obtained. Norepinephrine started for blood pressure support and fentanyl started for post-intubation sedation. Antibiotics and antifungals were started for broad spectrum coverage. The patient was emergently taken to the operating room for EGD, right tube thoracostomy, left thoracotomy and esophageal perforation repair with intercostal muscle flap, total pulmonary decortication, intercostal cryoablation, and diaphragm plication. No intra-operative complications were reported. The patient was transferred post-operatively to the cardiothoracic intensive care unit for further management.
Esophageal perforation is a surgical emergency, as leakage of gastric contents into the mediastinum causes a necrotizing inflammatory process and can lead to sepsis, multiorgan failure and death. Esophageal perforations are rare, with an incidence of 3.1 per 1 million per year. Perforations result from increased intraluminal pressure at anatomical sites of esophageal narrowing, as well as sites narrowed by malignancy. Over 50% of esophageal perforations are iatrogenic. Other etiologies include spontaneous perforation (15%), foreign body ingestion (12%), trauma (9%), intraoperative injury (2%) and malignancy (1%). The condition typically presents with severe retrosternal chest pain following major vomiting. 25-45% of patients have no history of vomiting. Primary management includes prompt diagnosis, patient stabilization, antibiotics, and assessment for operative management. Patients are often promptly taken to the operating room.

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