P1403 - A Life-Saving Abdominal CT Revealing a Spontaneous Esophageal Rupture

Abdul Rahman Al Armashi, MD¹, Eleonora Demyda, MD², Francisco J. Somoza-Cano, MD², Faris Hammad, MD², Kanchi Patell, MD², Hadeel Abuteer, MD², Keyvan Ravakhah, MD^2
1Saint Vincent Hospital, Parma, OH; ²Saint Vincent Hospital, Cleveland, OH

Introduction: Boerhaave’s syndrome, also known as effort rupture of the esophagus, is a medical condition that is fatal in the absence of therapy. Besides continuous vomiting, illnesses such as seizures, can raise the intra-esophageal pressure, leading to spontaneous esophageal perforation.

Case Description/Methods: Our patient is a 29-year-old male who presented to our hospital from a rehabilitation center where he was being managed for opioid withdrawal and intractable vomiting. On admission, he was complaining of dull epigastric pain with no radiation, associated with nausea and vomiting. Physical examination revealed an anxious mood, fever, tachycardia, and tachypnea. He also had decreased breath sounds bilaterally and mild periumbilical tenderness. His laboratory work showed leukocytosis and pre-renal acute kidney injury. Urine toxicology was positive for fentanyl. Bands, lactic acid, troponins, amylase and lipase were unremarkable. He was started on phenobarbital protocol for opioid withdrawal and hydration. Afterwards, he developed two tonic-clonic seizure episodes, aborted with lorazepam. A computed tomography (CT) scan of the abdomen revealed a tiny foci of air adjacent to the esophagus within the mediastinum (Figure 1- A). A CT scan of the chest exhibited pneumomediastinum extending into the cervical soft tissues and moderate thickening of the middle and distal end of the esophagus (Figure 1 - B, C). Unfortunately, a contrast esophagogram could not be performed as our patient was uncooperative and vitally unstable. He was started on broad-spectrum antibiotics and transferred to another facility where an emergent thoracic esophageal perforation repair was performed successfully.

Discussion: Boerhaave's syndrome is responsible for about 15% of esophageal ruptures. Clinical presentation and timing of the rupture are critical factors for determining the treatment and prognosis. Uncontained leak, clinical deterioration, sepsis, or pneumomediastinum progression are some of the indications for emergent surgical intervention. Moreover, the mortality rate exceeds 90% if left untreated, making it the most devastating cause of esophageal perforation. This case highlights that Boerhaave's syndrome should be suspected in patients with intractable vomiting and seizure disorder, as prompt clinical recognition is fundamental to prevent life-threatening consequences.


Figure: Figure 1- Panel A: CT scan of the abdomen showing a small foci of air adjacent to the esophagus within the mediastinum. Panel B, C: CT scan of the chest showing chest pneumomediastinum extending into the cervical soft tissues.


Disclosures:
Abdul Rahman Al Armashi indicated no relevant financial relationships.
Eleonora Demyda indicated no relevant financial relationships.
Francisco Somoza-Cano indicated no relevant financial relationships.
Faris Hammad indicated no relevant financial relationships.
Kanchi Patell indicated no relevant financial relationships.
Hadeel Abuteer indicated no relevant financial relationships.
Keyvan Ravakhah indicated no relevant financial relationships.


Abdul Rahman Al Armashi, MD¹, Eleonora Demyda, MD², Francisco J. Somoza-Cano, MD², Faris Hammad, MD², Kanchi Patell, MD², Hadeel Abuteer, MD², Keyvan Ravakhah, MD². P1403 - A Life-Saving Abdominal CT Revealing a Spontaneous Esophageal Rupture, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.