A 30-year-old man presents to the emergency department with severe chest pain that began suddenly after repeated, self-induced episodes of vomiting. He appears uncomfortable and diaphoretic. His vitals show a blood pressure of 100/65 mmHg, heart rate of 115 bpm, respiratory rate of 24 breaths per minute, and oxygen saturation of 94% on room air. On examination, you note crepitus on palpation of the chest wall and a “crunching” sound on cardiac auscultation. A chest X-ray reveals a widened mediastinum and subcutaneous emphysema. What is the next best step in management?
A) Endoscopy with esophageal dilation
B) Contrast esophagography with water-soluble contrast
C) Administration of proton pump inhibitor and discharge
D) Nasogastric tube placement and observation
Correct Answer: B) Contrast esophagography with water-soluble contrast
Explanation:
This patient’s presentation is highly suggestive of Boerhaave’s syndrome, which is a spontaneous esophageal perforation typically following forceful vomiting. The Mackler triad—vomiting, chest pain, and subcutaneous emphysema—is a classic but variably present feature.
- Chest X-ray findings can include pneumomediastinum, subcutaneous emphysema, and a pleural effusion (often left-sided).
- The next best step in management is contrast esophagography with a water-soluble contrast agent (e.g., Gastrografin), which helps confirm the diagnosis by demonstrating extravasation of contrast from the esophagus.
Why Not the Other Answers?
- (A) Endoscopy with esophageal dilation – Endoscopy is not the first-line test as it may exacerbate the tear. It is typically reserved for cases where contrast studies are inconclusive.
- (C) Proton pump inhibitor and discharge – This option is appropriate for Mallory-Weiss tears (a partial mucosal tear), but Boerhaave’s syndrome is a full-thickness rupture and requires urgent intervention.
- (D) Nasogastric tube placement and observation – Conservative management may be attempted in small, contained perforations in stable patients, but given this patient’s systemic symptoms and imaging, urgent diagnosis and surgical consultation are warranted.
Next Steps:
- Urgent surgical consultation is required, as most cases need operative repair.
- Broad-spectrum IV antibiotics and fluid resuscitation should be initiated promptly to prevent sepsis.
- NPO status and IV proton pump inhibitors can help minimize further esophageal injury.
Early recognition and management are critical, as delayed diagnosis significantly increases mortality in Boerhaave’s syndrome.
