Boerhaave Syndrome With Alkaline Pleural Effusion Kelechi Okoli, MD; Vamsee Marina, MD; Hussam Elkambergy, MD; Geetali Mohan, MD; Veejay Mahajan, MD OHIO THORACIC SOCIETY 57TH ANNUAL CONFERENCE 7 - 8 SEPTEMBER, 2007

Pleural Fluid pH in Esophageal Rupture Gastric acid reflux1? Bacterial metabolism? Neutrophil metabolism2? Only elimination of neutrophils prevented fall in pH in experimental esophageal rupture Abbott OA, Mansour KA, Logan WD, et al: Atraumatic so-called "spontaneous" rupture of the esophagus. J Thorac Cardiovasc Surg 59:6742, 1970 Good JT Jr, Antony VB, Reller LB, Maulitz RM, Sahn SA. The pathogenesis of the low pleural fluid pH in esophageal rupture. Am Rev Respir Dis. 1983 Jun;127(6):702-4

HPI 41 year-old type 1 diabetic Two days of nausea and vomiting PMH: ESRD, CVA, PE Uremia. Hyperkalemia. DKA Hemodialysis and insulin Resolution of clinical and biochemical abnormalities

HPI On fifth hospital day, he vomited Acute dyspnea BP 89/30mmHg; HR 128/min; RR 34/min; SaO2 83%; Temp 36.6oC Absent breath sounds over left hemithorax Portable CXR obtained

Intervention Left tube thoracostomy Left lung re-expansion Persistent air leak Non-ionic contrast esophagogram

Pleural Fluid pH – 7.51 LDH – 184 IU/L Protein – 2.8 g/dL Amylase – 2400 U/L No WBC seen Oral flora, Klebsiella, Haemophilus Blood . pH – 7.28 . LDH – 196 IU/L . Protein – 3.9 g/dL . WBC – 17.8 x 109 1. Corning pH meter

Outcome Left thoracotomy and decortication 2cm perforation in left posterolateral esophageal wall 3cm proximal to EGJ Complicated post-operative course Ventilator dependent Expired in palliative medicine unit

Conclusion Current case supports neutrophil metabolism Temporal relationship between symptom onset and pleural fluid sampling should be considered when esophageal rupture is suspected

Abstract