Esophageal perforation (Boerhaave syndrome)
History of inflammatory bowel disease. Presents with severe chest pain; no history of vomiting or instrumentation. Chest radiograph (not shown) with right-sided pleural effusion, mild pneumomediastinum and bilateral small pneumothoraces. Concern for oesophageal perforation.
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On the scout image, a thin crescent of gas outlines the bottom of the heart, compatible with pneumomediastinum. Bilateral chest tubes.
With the ingestion of Gastrografin, a right-sided esophageal leak into the pleural space quickly occurs. The leak crosses over slightly into the left pleural space and extends a little into the retrocrural/retroperitoneal space as well.
In this patient with no known risk factors for esophageal perforation (except inflammatory bowel disease and recent surgery), this would be considered a spontaneous esophageal perforation, also known as Boerhaave syndrome.
The classic presentation for Boerhaave syndrome is a history of severe vomiting (as seen with the index case, named by Dr. Boerhaave). The classic radiographic presentation is pneumomediastinum and a left-sided pleural effusion. In this case, the pleural effusion was predominantly right-sided.
An important point to remember is that one should always begin the study with water-soluble contrast (e.g. Gastrografin). If a perforation is found, then the study can be stopped. Barium is not typically used in this setting due to concern about possible mediastinitis and barium's long term effects in the pleural space. A controversial scenario occurs there is a strong concern for esophageal perforation and no leak seen with Gastrografin. Some advocate that high density barium is more likely to reveal a subtle leak in this setting, but the risk of barium in the pleural space has to be carefully weighed against missing a small subtle esophageal perforation, which could be fatal if not diagnosed. Caution, judgment, and the level of clinical suspicion must come into play if considering this approach.