Presentation and diagnosis

Presentation and diagnosis

Sometimes the history is obvious, such as after instrumenta - - tion or foreign body ingestion. At other times there may not have been any precipitating cause. Patients with Boerhaave’s syndrome may have the classic triad of vomiting , chest pain and subcutaneous emphysema. There may or may not be asso - - ciated haematemesis. Typically , the site of perforation is the lower oesophagus towards the left pleural cavity . Gastric juice as well as ingested food is forcefully ejected into the left chest. A left pleural e ff usion rapidly accumulates. Physical examination r eveals subcutaneous emphysema on the chest wall, sometimes extending to the cervical region as well. In the presence of sepsis, the patient will run a fever, has tachycardia and appears tachypnoeic. Hamman’s sign refers to a crunching sound on auscultation of the heart owing to surgical emphysema. Di ff erential diagnoses usually include pneumonia, myocardial ischaemia or other intra-abdominal pathologies such as a perforated viscus when the pain is referred to the epigastrium. Patients with cervical oesophageal or pharyngeal perfora tion are usually much less septic than those with intrathoracic perforations and mediastinitis. A typical example would be foreign body perforation, such as by a shar p fishbone, having lodged at the postcricoid area and perforated the oesophagus. There may be a history of foreign body ingestion and neck pain and physical examination may reveal tenderness and sub cutaneous emphysema. Subcutaneous and mediastinal air, pneumothorax, hydro pneumothorax and a widened mediastinum may be seen on the chest radiograph ( Figure 66.5 ). Contrast swallow study using Gastrografin or a non-ionic contrast usually re veals the site of perforation. However, sick patients may not be able to tolerate oral contrast. A CT scan (preferably with intravenous as well as oral contrast) will be able to demonstrate the site (and aetiology) of perforation and the extent of mediastinitis, e ff usion and collections ( Figure 66.6 ).