Lab Case 116 – Interpretation

A 31 year old man with severe metabolic derangement following vomiting, with chest pain. Blood results suggest severe/ prolonged vomiting.Severe metabolic alkalosis

appropriate respiratory compensation (possible additional respiratory acidosis, however venous gas)

severe hypokalaemia requires urgent potassium replacement

moderate hyponatraemia, severe hypochloraemia – HCL loss from stomach

Boerhaave syndrome.

Meckler triad –  vomiting, lower thoracic pain, and subcutaneous emphysema.

Presentation depends on the following:

  • The location of the tear -Patients with cervical esophagus perforation may present with neck or upper chest pain.Patients with middle or lower esophagus perforation may present with interscapular or epigastric discomfort
  • The cause of the injury
  • The amount of time that has passed from the perforation to the intervention

Clinical Signs:

Pleural effusion.

Subcutaneous emphysema – 28-66% of patients will have this at initial presentation. More typically, subcutaneous emphysema is found later.

Tachypnea and abdominal rigidity.

Tachycardia, diaphoresis, fever, and hypotension are common, particularly as the illness progresses. However, these findings are nonspecific.

Unusual findings may include the following:

  • Peripheral cyanosis
  • Hoarseness of voice due to recurrent laryngeal nerve involvement
  • Tracheal and mediastinal shift
  • Cervical vein distention
  • Proptosis

Pneumomediastinum is a very important finding. It may cause a crackling sound upon chest auscultation, known as the Hamman crunch. The crunch typically is heard coincident with each heartbeat and may be mistaken for a pericardial friction rub. This is present in 20% of patients.

Later stages of illness may manifest with signs of infection and sepsis. Symptoms may include fever, hemodynamic instability, and progressive obtundation. Establishing a diagnosis in the later stages can be quite difficult because septic complications begin to dominate the clinical picture. Early diagnosis is critical.

 

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