Ch. 51 Chest Pain After Vomiting

Question 1

What is Mackler’s Triad?

Answer 1

Vomiting, thoracic pain, subcutaneous emphysema

Highly suggestive of Boerhaave’s syndrome

Question 2

Major differences between Boerhaave’s syndrome and Mallory-Weiss:

Answer 2

Boerhaave =

• full-thickness rupture of esophagus 2/2 increased intragastric pressure
  
  • posterolateral aspect of distal esophagus = most common location
• thoracic pain radiating to back, L-sided pleural effusion, signs of sepsis
• IMMEDIATE SURGICAL REPAIR AND DRAINAGE

MW

• partial tear of muscosa at GEJ 2/2 “ “
• upper GI bleed
• most resolve spontaneously; surgery rarely indicated

Question 3

Why do patients with boerhaave’s syndrome become so septic?

Answer 3

Esophageal perforation –> gross contamination of mediastinum

Perforation often leads to rupture of the pleura as well, likely 2/2 to gastric and bilious contents eroding through the lining… once pleura has been disrupted, gross contamination of pleural cavity also occurs

** it is this MEDIASTINITIS and PLEURITIS that eventually –> sepsis and multiorgan failure –> untreated? death **

Question 4

What kind of contrast should be used in diagnosing boerhaave’s syndrome?

Answer 4

Water-soluble contrast b/c barium escaping out of the esophagus may cause severe inflammatory rxn in mediastinum or pleura

Question 5

Pleural decortication

Answer 5

Debridement of the mediastinum + pleura prior to surgical closure

Question 6

Prognosis:

• Mortality rate?
• Cause of death?

Answer 6

• Mortality rate = 50%
• Death occurs 2/2 contamination of mediastinum + pleura –> sepsis, septic shock, multiorgan failure

Question 7

What is Hamman’s Sign?

Answer 7

“Mediastinal crunch or clicking” produced by the heart beating against air-filled tissues