30 yo M with nausea/vomiting and chest pain

OBJECTIVES: 

  • Identify soft tissue abnormalities on chest x-ray

CASE: 

A 30 yo M with cyclic vomiting syndrome comes in with 3 days of worsening nausea/vomiting and 1 day of chest pain and shortness of breath. He reports 30 episodes of emesis over the past 3 days, initially bilious, but his most recent episodes have had small amounts of blood. He reports subjective fevers, chills, diaphoresis and new onset chest pain, neck pain and shortness of breath over the past day. He additionally reports new hoarseness over the past day.

His vital signs are notable for T 37.7C, HR 120s, BPs 130/80, RR 22, SaO2 95% on RA. His initial labs are notable for WBC of 32 with left shift, hct of 39. CMP, lipase, and coagulation markers are normal.

His chest x-ray shows the following:


What is your differential for this finding?


What is your next step in diagnosis? 


How would you manage him now? 


OUTCOME: 

TAKE HOME POINTS: 


REFERENCES:

  1. Triadilfilopoulis, G. “Boerhaave syndrome: Effort rupture of the esophagus.” Grover, S, ed. UpToDate. Waltham, MA. UpToDate, Inc. https://www-uptodate-com (Accessed on October 20, 2017).
  2. Blencowe, NS. 2013. Spontaneous oesophgaeal rupture. BMJ. 346;f3095.