Pleural Effusions

Case Presentation:

80 year old female with a past history of hypertension, renal cell carcinoma, and status post-nephrectomy, experienced episodes of choking, coughing and vomiting when trouble swallowing her Centrum Silver tablet. Shortly after the vomiting, the patient develops severe chest pain with radiation to leđima.Bol was significantly worse with deep inspiration.

Introduction:

Boerhaave's syndrome spontaneous rupture of the esophagus, classically described as a post-emetic, but can also occur when lifting heavy weight, with severe asthma, cough or dugotrajno.Nagli intraluminar increase in esophageal pressure causes esophageal tear, which usually occurs in the lower esophagus above the left diaphragm.

Boerhaave syndrome was first described in 1724 Hermann Boerhaave, Dutch physician. His patient was 50 years old Admiral (Baron Ivan van Waasenaer) who developed a sudden excruciating pain in the chest and strain on povraćanje.Pacijent developed shock and died 18 hours kasnije.Obdukcija showed rupture of the distal esophagus in the left chest.

Clinical Presentation:

classic, the patient is middle-aged, white male with a history of overindulgence in food or piće.Pacijent often develops vomiting, lower chest pain, and mediastinal or subcutaneous emphysema (Meckler's triad - vomiting, pain and subcutaneous emphysema).

physical examination usually reveals a critically ill patient, usually sitting in bed with front squatting position. Subcutaneous emphysema is often seen. Hamman sign is seen in up to 20 percent of patients Boerhaave. Hamman's sign crunching, rasping sound, synchronous with heartbeat, heard over the precordium, and often shows spontaneous mediastinal emphysema. Patients will present with varying degrees of epigastric tenderness, sometimes mimicking intra-abdominal catastrophe. When the rupture is confined to the mediastinum, the patient May not look particularly sick and vital signs can be deceptively normal.

Differential diagnosis:

the differential diagnosis of Boerhaave syndrome is extensive and should include the following:

° Perforated or bleeding ulcer

Acute pancreatitis

° myocardial infarction

° pulmonary embolus

° dissecting aneurysm

° Spontaneous Pnuemothorax

° Mallory-Weiss Tear

Acute cholecystitis

Diagnostic Rating:

In addition to patient history, radiography remains the cornerstone of diagnostic evaluation for Boerhaave's syndrome. Plain radiographs of the chest may show mediastinal or free peritoneal air (usually located on the original films), widened mediastinum, hyrdrothorax, hydropneumothorax or mediastinal emphysema. Ten to fifteen percent of all patients with Boerhaave's syndrome may have normal plain x-ray suitcase.

X-ray contrast swallow studies remain the diagnostic gold standard. Or thoracic CT and esophagram is necessary to locate the exact site of perforation, and helps to determine the best surgical pristup.Topiv water contrast agents, such as gastrografin used. Most recommend avoiding barium from its peak in thorcacic cavity can cause an inflammatory reaction leading to granuloma formation.

Management:

initial emergency department management of Boerhaave's syndrome includes strict NPO, broad-spectrum antibiotics, fluid resuscitation, and continuous nasal gastric usisavanja.Kardijalni surgeon should be consulted immediately, and if cardiovascular services are not available to your facility, the patient should be transferred to the appropriate facility.

patients are often placed on total parenteral nutrition, and early surgical repair remains the standard of care. Complications in Boerhaave syndrome include persistent esophageal leak, Mediastinitis, polymicrobial sepsis, pneumonia and empyema.

Despite optimal management, mortality in patients with Boerhaave's syndrome remains high. Mortality rates are quoted as high as 72 percent, and most likely attributed to the difficulty in making a diagnosis. In contrast to the spontaneous rupture of the esophagus, iatrogenic esophageal rupture carries a mortality rate of only 20 percent, and traumatic perforation has a mortality rate of only 7 percent.

Conclusion Subject:

the patient was treated in the emergency department with aspirin, morphine, Reglan, one liter of saline, Zosyn 3.375 grams of intravenous and nasogastric tube is stavljen.Torakalne CT with oral administration of 20 mL Redicat showed bilateral pleural effusion, a tract contrast, the air above the front wall of the esophagus.

semi-erect a contrast esophagram with thin barrium solution showed esophageal tear with a short esophageal stricture in the mid to distal third of the esophagus.

gastro-intestinal and cardio-Thoracic Surgery Service were consulted and the patient was transferred to ICU

References:

1 Online uptodate 13.2, Boerhaave's syndrome: Effort rupture of the esophagus. 2005th

2 Hospital Doctor, 55-year-old man with chest pain, November 2005.

3 Emergency physician Boerhaave syndrome Monthly, January 2006.

4 Khan AZ, Strauss D, Mason RC. Boerhaave's syndrome: diagnosis and surgical treatment. Surgeon. 2007 February;. 5 (1) :39-44

5 Bottle CM, Whyte RI. Boerhaave's syndrome: diagnosis and treatment. Med Surg North Am. 2005 June;. 85 (3) :515-24

6 Janjua KJ. Boerhaave syndrome. Postgrad Med J. 1997 May;. 73 (859) :265-70