A12) Hematemesis and chest pain

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with chest pain.
  2. Review the DDx considerations in a patient with chest pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with chest pain.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
This patient with several episodes of vomiting after a recent esophageal balloon dilation likely has Boerhaave syndrome, or esophageal rupture. Air tracking from the esophageal rupture may cause subcutaneous emphysema, as suggested in this case by the crepitus on palpation of the chest wall. Patients may also have pleural effusions from the gastric contents, as suggested in diminished sounds at the lung bases on physical exam.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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This patient requires urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

A chest X-ray is an appropriate and quickly obtainable initial imaging modality.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

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Second Imaging Study

What is the next imaging study you will order?

A CT esophagram should be ordered to confirm the diagnosis of esophageal rupture.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

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View the full study if you'd like to like a look yourself

Third Imaging Study

What is the next imaging study you will order?

No further imaging is needed as the diagnosis is confirmed with the CT scan.

What is your Diagnosis now that you have seen the imaging results?

The most likely diagnosis is Boerhaave’s Syndrome given their presentation and imaging findings.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

The patient requires urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 50-year-old male presenting with sepsis, severe chest pain, and hematemesis after episodes of vomiting due to food poisoning following a recent esophageal balloon dilation. A CT esophagram was consistent with a diagnosis of esophageal rupture, or Boerhaave syndrome. Thoracic surgery should be urgently consulted. In the interim, he should be made NPO and started on fluids, broad spectrum antibiotics, and an IV proton-pump inhibitor.

Lessons Learned:
- Boerhaave syndrome can occur due to an esophageal endoscopy and balloon dilation and severe vomiting.
- Patients presenting with esophageal rupture usually have an underlying, long-standing esophageal disorder.
- Boerhaave syndrome should be suspected in a patient with severe chest, neck, or abdominal pain following severe forceful emesis. It sometimes presents as the “Mackler triad” of vomiting, chest pain, and subcutaneous emphysema. It can also lead to sepsis.
- A chest X-ray can reveal pneumomediastinum and subcutaneous emphysema.
- A CT esophagram can confirm the diagnosis by demonstrating extravasation of contrast from the esophagus. 

Socioeconomic Factors: In a case such as this one where the diagnosis is strongly suspected, a CT prior to a chest X-ray is also an appropriate decision-making pathway.

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