- Email: [email protected]
Esophageal rupture diagnosed with bedside ultrasound
American Journal of Emergency Medicine (2012) 30, 2093.e1–2093.e3
www.elsevier.com/locate/ajem
Case Report Esophageal rupture diagnosed with bedside ultrasound Abstract A 69-year-old man presented to the emergency department with hematemesis, hypotension, tachycardia, and hypothermia. The emergency physician performed a bedside ultrasound of the chest, heart, and abdomen. The heart was unable to be visualized in the parasternal, apical, or subxiphoid windows, and free fluid and particulate matter were visualized in the chest and abdomen. The inability to visualize the heart in the normal cardiac windows suggested a diagnosis of pneumopericardium. Based upon the patient's presenting symptoms and ultrasound findings, an esophageal perforation was suspected. Esophageal perforation is a medical emergency. Deterioration and death due to sepsis can occur within hours of presentation [6]. Although there is a great deal of literature discussing the diagnosis of esophageal perforation by chest radiograph, computed tomography (CT), and esophagography, there are no articles on the role of ultrasound. Esophageal perforation may result in the communication of air between the esophagus and pericardium and the leakage of gastric contents into the chest and peritoneal cavity. The presence of air in the pericardial sac results in nonvisualization of the heart on ultrasound. Fluid in the chest and abdomen may be visualized in the posterior upper abdominal windows. Although these ultrasound findings alone are not entirely specific for esophageal perforation, when coupled with a high index of suspicion due to the patient presentation, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques to make the diagnosis of esophageal perforation. A 69-year-old man presented to the emergency department (ED) with hematemesis 1 week after an upper endoscopy and colonoscopy. The patient's initial blood pressure was 48/33 with a heart rate of 103. His temperature was 92.5°F. The patient had some dried blood at the nares but a clear oropharynx. Rhonchial breath sounds were heard 0735-6757/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
throughout both lungs. The abdomen was soft and nondistended with moderate epigastric tenderness. A bedside ultrasound was performed of the chest, heart, and abdomen. The heart could not be visualized in the parasternal, apical, or subxiphoid windows, suggesting pneumopericardium (Fig. 1). Free fluid and particulate matter were visualized in the chest and abdomen (Figs. 2 and 3). Considering the patient's presentation, pneumopericardium, and the free fluid seen on ultrasound in the chest and abdomen, an esophageal perforation was suspected, and the surgical team was consulted. In surgery, a small hole found in the distal esophagus was repaired. The right pleural cavity was found to contain 350 mL of feculent material and was lavaged with antibiotic solution. Bilateral chest tubes were placed. The patient remained afebrile and hemodynamically stable for the rest of his hospital stay and was discharged on hospital day 26. With the introduction of the flexible endoscope in the 1960s, the frequency of esophageal perforation from esophagogastroduodenoscopy decreased from 0.1% to 0.03% [1-3], although this risk can be as high as 17%, depending upon the severity of underlying disease and operator experience [4]. The increased availability of endoscopy allows more procedures to
Fig. 1 The heart could not be visualized by ultrasound because of the presence of pneumopericardium (parasternal long axis view).
2093.e2
Fig. 2 Anechoic fluid collection (asterix) located superior to the diaphragm (arrow) in a coronal view of the left thoracic cavity.
be undertaken, inherently increasing the incidence of complications. It is estimated that around 33-75% of all esophageal perforations are iatrogenic with the remainder secondary to trauma, foreign bodies, pills, infections, caustic agents, and vomiting [5]. Esophageal perforation, from any cause, is a medical emergency. The influx of gastric contents into the chest cavity causes a massive inflammatory response as well as infection, leading to the rapid onset of pain, tachycardia, dyspnea, and fever. Deterioration and death due to sepsis can occur within hours of symptoms [6]. The classic presentation of spontaneous esophageal rupture, known as “Mackler's triad,” is composed of vomiting, chest pain, and the presence of subcutaneous emphysema. Patients may exhibit “Hammon's crunch,” which is a crackling sound synchronized with the heartbeat due to pneumomediastinum. In 1 study of 13 patients with
Fig. 3 Anechoic fluid collection (asterix) containing particulate matter located inferior to the diaphragm in a coronal view of the left upper quadrant.
Case Report confirmed spontaneous esophageal perforation, the most common presenting symptoms included chest pain, dysphagia, dyspnea, and subcutaneous emphysema after vomiting [7]. The signs and symptoms of esophageal perforation can vary widely, however; therefore, a high index of clinical suspicion is vital to making a prompt diagnosis. Along with signs and symptoms, radiologic imaging is needed for diagnosis. In a retrospective study of 14 patients with confirmed esophageal perforation, the diagnostic value of chest radiography and CT were compared with the criterion standard of contrast esophagography. Contrast esophagography allowed for localization of the perforation site; however, it had a false-negative rate of 36% [8]. The study also showed chest radiography to be very sensitive but not specific for esophageal perforation, whereas it showed CT to be much more specific [8]. Although there is a great deal of literature discussing the diagnosis of esophageal perforation by chest radiograph, CT, and esophagography, there are no articles on the role of ultrasound. Ultrasound has become a widely used tool in the ED due to its ability to positively impact patient care in critical settings. Although chest radiography is a relatively quick method to detect perforation, 1 study, which discussed the use of radiography vs ultrasound in the detection of hemothorax, revealed that a bedside ultrasound could be completed in 1.3 minutes on average, whereas the chest radiograph may not be available for 14.2 minutes [9]. Despite the high specificity of CT and esophagography in detecting esophageal perforation, both are more time consuming, more expensive, and much more invasive to the patient than ultrasound. Esophageal perforation may result in the communication of air between the esophagus and pericardium and the leakage of gastric contents into the chest and peritoneal cavity. Sonographic signs of pneumopericardium include nonvisualization of the heart (due to poor sound wave conduction through pericardial air) and the “air gap sign” (visualized in M-mode as the contraction of the heart displaces air in the pericardium anteriorly, preventing a sonographic image) [10]. In addition, the inability to visualize the heart in all echocardiographic windows helps to distinguish pneumopericardium from pneumomediastinum in which visualization of the heart is generally preserved in the subxiphoid approach [11]. Thus, in a patient with epigastric pain and vomiting, the inability to visualize the heart on ultrasound in combination with the identification of fluid and particulate matter in the chest and/or abdomen suggests esophageal perforation. Ultimately, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques to make the diagnosis of esophageal perforation at patient's bedside. Charlotte Derr MD Jessica Maloney Drake MD University of South Florida, FL, USA http://dx.doi.org/10.1016/j.ajem.2011.12.036
Case Report
References [1] Schaffner JA. Gastrointestinal endoscopy. In: Parrillo JE, Dellinger RP, editors. Critical care medicine: principles of diagnosis and management in the adult. St. Louis (Mo): Mosby; 2001. p. 260-70. [2] Silvis SE, Nebel O, Rogers G, et al. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976;235: 928-30. [3] Kavic SM, Basson MD. Complications of endoscopy. Am J Surg 2001;181:319-32. [4] Bhatia NL, Collins JM, Nguyen CC, Jaroszewski DE, Vikram HR, Charles JC. Esophageal perforation as a complication of esophagogastroduodenoscopy. J Hosp Med 2008;3:256-62. [5] Duncan M, Wong RK. Esophageal emergencies: things that will wake you from a sound sleep. Gastroenerol Clin N Am 2003;32: 1035-52.
2093.e3 [6] Wu JT, Mattox KL, Wall MJ. Esophageal perforations: new perspectives and treatment paradigms. J Trauma 2007;63:1173-84. [7] Forshaw MJ, et al. Vomiting-induced pneumomediastinum and subcutaneous emphysema does not always indicate Boerhaave's syndrome: report of six cases. Surg Today 2007;37:888-92. [8] Ghanem N, Altehoefer C, Springer O, et al. Radiological findings in Boerhaave's syndrome. Emerg Radiol 2003;10:8-13. [9] Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in detection of hemothorax. Ann Emerg Med 1997;29: 312-5. [10] Antonini-Canterin F, Nicolosi GL, Mascitelli L, Zanuttini D. Direct demonstration of an air-fluid interface by two-dimensional echocardiography: a new diagnostic sign of hydropneumopericardium. J Am Soc Echocardiogr 1996;9:187-9. [11] Allgood NL, Brownlee JR, Green GA. Inability to view the heart through the subxiphoid echocardiographic window: a harbinger of disaster. Pediatr Cardiol 1994;15:27-9.
www.elsevier.com/locate/ajem
Case Report Esophageal rupture diagnosed with bedside ultrasound Abstract A 69-year-old man presented to the emergency department with hematemesis, hypotension, tachycardia, and hypothermia. The emergency physician performed a bedside ultrasound of the chest, heart, and abdomen. The heart was unable to be visualized in the parasternal, apical, or subxiphoid windows, and free fluid and particulate matter were visualized in the chest and abdomen. The inability to visualize the heart in the normal cardiac windows suggested a diagnosis of pneumopericardium. Based upon the patient's presenting symptoms and ultrasound findings, an esophageal perforation was suspected. Esophageal perforation is a medical emergency. Deterioration and death due to sepsis can occur within hours of presentation [6]. Although there is a great deal of literature discussing the diagnosis of esophageal perforation by chest radiograph, computed tomography (CT), and esophagography, there are no articles on the role of ultrasound. Esophageal perforation may result in the communication of air between the esophagus and pericardium and the leakage of gastric contents into the chest and peritoneal cavity. The presence of air in the pericardial sac results in nonvisualization of the heart on ultrasound. Fluid in the chest and abdomen may be visualized in the posterior upper abdominal windows. Although these ultrasound findings alone are not entirely specific for esophageal perforation, when coupled with a high index of suspicion due to the patient presentation, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques to make the diagnosis of esophageal perforation. A 69-year-old man presented to the emergency department (ED) with hematemesis 1 week after an upper endoscopy and colonoscopy. The patient's initial blood pressure was 48/33 with a heart rate of 103. His temperature was 92.5°F. The patient had some dried blood at the nares but a clear oropharynx. Rhonchial breath sounds were heard 0735-6757/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
throughout both lungs. The abdomen was soft and nondistended with moderate epigastric tenderness. A bedside ultrasound was performed of the chest, heart, and abdomen. The heart could not be visualized in the parasternal, apical, or subxiphoid windows, suggesting pneumopericardium (Fig. 1). Free fluid and particulate matter were visualized in the chest and abdomen (Figs. 2 and 3). Considering the patient's presentation, pneumopericardium, and the free fluid seen on ultrasound in the chest and abdomen, an esophageal perforation was suspected, and the surgical team was consulted. In surgery, a small hole found in the distal esophagus was repaired. The right pleural cavity was found to contain 350 mL of feculent material and was lavaged with antibiotic solution. Bilateral chest tubes were placed. The patient remained afebrile and hemodynamically stable for the rest of his hospital stay and was discharged on hospital day 26. With the introduction of the flexible endoscope in the 1960s, the frequency of esophageal perforation from esophagogastroduodenoscopy decreased from 0.1% to 0.03% [1-3], although this risk can be as high as 17%, depending upon the severity of underlying disease and operator experience [4]. The increased availability of endoscopy allows more procedures to
Fig. 1 The heart could not be visualized by ultrasound because of the presence of pneumopericardium (parasternal long axis view).
2093.e2
Fig. 2 Anechoic fluid collection (asterix) located superior to the diaphragm (arrow) in a coronal view of the left thoracic cavity.
be undertaken, inherently increasing the incidence of complications. It is estimated that around 33-75% of all esophageal perforations are iatrogenic with the remainder secondary to trauma, foreign bodies, pills, infections, caustic agents, and vomiting [5]. Esophageal perforation, from any cause, is a medical emergency. The influx of gastric contents into the chest cavity causes a massive inflammatory response as well as infection, leading to the rapid onset of pain, tachycardia, dyspnea, and fever. Deterioration and death due to sepsis can occur within hours of symptoms [6]. The classic presentation of spontaneous esophageal rupture, known as “Mackler's triad,” is composed of vomiting, chest pain, and the presence of subcutaneous emphysema. Patients may exhibit “Hammon's crunch,” which is a crackling sound synchronized with the heartbeat due to pneumomediastinum. In 1 study of 13 patients with
Fig. 3 Anechoic fluid collection (asterix) containing particulate matter located inferior to the diaphragm in a coronal view of the left upper quadrant.
Case Report confirmed spontaneous esophageal perforation, the most common presenting symptoms included chest pain, dysphagia, dyspnea, and subcutaneous emphysema after vomiting [7]. The signs and symptoms of esophageal perforation can vary widely, however; therefore, a high index of clinical suspicion is vital to making a prompt diagnosis. Along with signs and symptoms, radiologic imaging is needed for diagnosis. In a retrospective study of 14 patients with confirmed esophageal perforation, the diagnostic value of chest radiography and CT were compared with the criterion standard of contrast esophagography. Contrast esophagography allowed for localization of the perforation site; however, it had a false-negative rate of 36% [8]. The study also showed chest radiography to be very sensitive but not specific for esophageal perforation, whereas it showed CT to be much more specific [8]. Although there is a great deal of literature discussing the diagnosis of esophageal perforation by chest radiograph, CT, and esophagography, there are no articles on the role of ultrasound. Ultrasound has become a widely used tool in the ED due to its ability to positively impact patient care in critical settings. Although chest radiography is a relatively quick method to detect perforation, 1 study, which discussed the use of radiography vs ultrasound in the detection of hemothorax, revealed that a bedside ultrasound could be completed in 1.3 minutes on average, whereas the chest radiograph may not be available for 14.2 minutes [9]. Despite the high specificity of CT and esophagography in detecting esophageal perforation, both are more time consuming, more expensive, and much more invasive to the patient than ultrasound. Esophageal perforation may result in the communication of air between the esophagus and pericardium and the leakage of gastric contents into the chest and peritoneal cavity. Sonographic signs of pneumopericardium include nonvisualization of the heart (due to poor sound wave conduction through pericardial air) and the “air gap sign” (visualized in M-mode as the contraction of the heart displaces air in the pericardium anteriorly, preventing a sonographic image) [10]. In addition, the inability to visualize the heart in all echocardiographic windows helps to distinguish pneumopericardium from pneumomediastinum in which visualization of the heart is generally preserved in the subxiphoid approach [11]. Thus, in a patient with epigastric pain and vomiting, the inability to visualize the heart on ultrasound in combination with the identification of fluid and particulate matter in the chest and/or abdomen suggests esophageal perforation. Ultimately, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques to make the diagnosis of esophageal perforation at patient's bedside. Charlotte Derr MD Jessica Maloney Drake MD University of South Florida, FL, USA http://dx.doi.org/10.1016/j.ajem.2011.12.036
Case Report
References [1] Schaffner JA. Gastrointestinal endoscopy. In: Parrillo JE, Dellinger RP, editors. Critical care medicine: principles of diagnosis and management in the adult. St. Louis (Mo): Mosby; 2001. p. 260-70. [2] Silvis SE, Nebel O, Rogers G, et al. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976;235: 928-30. [3] Kavic SM, Basson MD. Complications of endoscopy. Am J Surg 2001;181:319-32. [4] Bhatia NL, Collins JM, Nguyen CC, Jaroszewski DE, Vikram HR, Charles JC. Esophageal perforation as a complication of esophagogastroduodenoscopy. J Hosp Med 2008;3:256-62. [5] Duncan M, Wong RK. Esophageal emergencies: things that will wake you from a sound sleep. Gastroenerol Clin N Am 2003;32: 1035-52.
2093.e3 [6] Wu JT, Mattox KL, Wall MJ. Esophageal perforations: new perspectives and treatment paradigms. J Trauma 2007;63:1173-84. [7] Forshaw MJ, et al. Vomiting-induced pneumomediastinum and subcutaneous emphysema does not always indicate Boerhaave's syndrome: report of six cases. Surg Today 2007;37:888-92. [8] Ghanem N, Altehoefer C, Springer O, et al. Radiological findings in Boerhaave's syndrome. Emerg Radiol 2003;10:8-13. [9] Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in detection of hemothorax. Ann Emerg Med 1997;29: 312-5. [10] Antonini-Canterin F, Nicolosi GL, Mascitelli L, Zanuttini D. Direct demonstration of an air-fluid interface by two-dimensional echocardiography: a new diagnostic sign of hydropneumopericardium. J Am Soc Echocardiogr 1996;9:187-9. [11] Allgood NL, Brownlee JR, Green GA. Inability to view the heart through the subxiphoid echocardiographic window: a harbinger of disaster. Pediatr Cardiol 1994;15:27-9.