Esophageal rupture Christine Young, MS4 Paul Lewis, MD

CC: Substernal and Epigastric pain HPI: Pt is a 80 yo M with PMH of HTN, COPD, OSA and hx of recurrent GI bleeding who presents as a transfer from OSH with concern for esophageal rupture s/p enteroscopy for recurrent small bowel AVM bleeding. Post-procedure, pt developed increased SOB and severe epigastric/substernal chest pain with radiation to back. CT chest showed evidence of esophageal rupture at level of carina, and pt transferred to RUMC for emergent intervention. VS: HR 103 BP: 163/74 T: RR: 34 SpO2: 93 % on 5L NC Exam: Chest – Hamman’s sign (anterior mediastinal crunch), fair air movement. Abdomen-epigastric tenderness to palpation. Patient presentation 2

1.CXR – Upright PA and lateral chest. – diagnostic in 90% of cases of esophageal rupture. 2.CT chest without contrast – Air in the mediastinum surrounding esophagus is the most diagnostic finding of esophageal rupture. 3.Barium swallow (fluoroesophagram) – Barium esophagram following plain radiography may be performed to look for extravasation of contrast and location and extent of rupture/tear. Diagnostic Imaging Options:

CT chest without IV MRN:

CT chest with contrast

Coronal view CT

Fluoroesophagram

Surgical findings: Cardiothoracic surgery placed esophageal stent via right lateral approach that resulted in partial lung resection (R lower lobe). Operative report: – 1 cm esophageal perforation from 33 to 34 cm from incisors. – Adhesions and calcified pleural plaques from asbestos exposure.

CXR

Fluoroesophagram

Clinical status/follow up Esophageal stent evaluated post-op with fluoroesophagram that was negative for esophageal leak. Patient’s post-op course included a prolonged hospital stay due to other medical issues (v-tach episode that self- corrected, received cardiac work-up to determine etiology).