Chest Xray Quiz 5
A 58 year old man with a history of alcohol dependence present with fevers, shortness of breath, chest pains and lethargy. He has been unwell for several days with nausea and vomiting.
He arrives in the emergency department appearing toxic, with a blood pressure of 90mmHg systolic, a heart rate of 130bpm and oxygen saturations on room air of 89%.
The following Chest Xray is taken. What does it show? What is the likely diagnosis?
The most striking abnormality is that there is a large quantity of air in the mediastinum, extending into the root of the neck, but not in the subcutaneous tissues of the thorax. This represents a pneumomediastinum.
There is also haziness overlying the left hemidiaphragm and loss of the left costophrenic angle, consistent with a pleural effusion.
This combination is likely to represent lower oesophageal rupture, also known as Boerhaave's Syndrome.
Oesophageal rupture is usually associated with forceful vomiting, sometimes against a closed obstruction. The mortality rate is very high, requiring prompt diagnosis and emergent surgical management.
The classic Xray findings are mediastinal air and a left sided pleural effusion +/- pneumothorax.
The tissue planes in the mediastinum are contiguous with those of the neck, allowing air to track upwards. These planes however do not extend into the chest, giving this characteristic Xray appearance.
The most common site of perforation is in the lower oesophagus, 3-6cm above the diaphragm . In most cases the rupture is on the left posterolateral aspect of the oesophagus, leading to a left sided pleural effusion.
1. de Schipper JP, Pull ter Gunne AF, Oostvogel HJ et-al. Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Dig Surg. 2009;26 (1): 1-6.
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