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The Case Files

A Significant Injury with Just a Speck of Pain

Bharadwaj, Arjun; Malik, Khalid, MD

doi: 10.1097/01.EEM.0000547427.32118.2a
The Case Files

Mr. Bhardwajis a third-year medical student at the University of Medicine and Health Science, and is currently doing his emergency medicine rotation at Weiss Memorial Hospital in Chicago, IL. Dr. Malikis a board-certified emergency and internal medicine physician and the director of the emergency department at Weiss Memorial Hospital, an affiliate of the University of Illinois Hospital.

Figure 1

Figure 1

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A 58-year-old man who lived at a nursing facility came to the emergency department complaining of abdominal pain for three days. His pain was localized to the epigastrium and periumbilical regions. The nursing home staff indicated that he was hypotensive and possibly hypoxic.

The patient said he never had similar pain before, which he said pain was mild and constant in severity and did not radiate to the chest, back, pelvis, or shoulders. He also reported nausea but no trauma, falls, vomiting, fever, chills, dizziness, chest pain, shortness of breath, trouble walking, or change in bowel movements or urination.

He had a history of schizoaffective disorder, type 2 diabetes mellitus, hypertension, and hyperlipidemia. He said he did not use illicit drugs and that he had quit smoking more than three years before. He used to consume ethanol daily, but had stopped when he was admitted to the nursing home two years earlier. His vital signs were a heart rate of 116 bpm, a blood pressure of 70/42 mm Hg, a temperature of 97.1°F, a respiration rate of 29 bpm, an oxygen saturation of 97% on two L nasal cannula, and pain severity of 2/10.

His neck and pharynx were normal, and he had no tenderness to chest or chest wall palpation. His breathing was not labored, but he had decreased bilateral breath sounds. A cardiac exam showed a regular rate and rhythm, he had no peripheral edema, and his peripheral pulses were equal bilaterally. His abdomen was soft, flat, and without organomegaly, and bowel sounds were normo-active. There was mild tenderness in the epigastric region without rebound, and Murphy's sign was negative. Rectal sphincter tone was maintained, and the guaiac test was negative. His skin was warm, dry, and of normal color. The remainder of the examination was normal.

Figure 2

Figure 2

He was taking simvastatin, metformin, insulin detemir/aspart, lactulose, haloperidol, fenofibrate, divalproex, clozapine, chlorpromazine, benztropine, aspirin, and multivitamin-min-iron-FA-vit K. Based on his history and physical exam, the differential diagnosis was narrowed to pneumonia with sepsis, pulmonary embolism, myocardial infarction, and intra-abdominal sepsis.

Figure 3

Figure 3

Labo results showed a WBC count of 8.3 k/μL, Hct of 30.5%, Hbg of 10.4 g/dL, RBC count of 3.71 M/μL, lactic acid of 9 mmol/L, PT of 12 s, and troponin of <0.03 ng/dL. An ECG revealed sinus tachycardia without ischemic changes. Chest x-ray showed near-complete left hemithorax opacification (Fig. 1), which was evocative of massive pleural effusion or consolidation of the left lung. The patient at this time had a Glasgow Coma Scale score below 7, and was intubated and placed on a ventilator. Abdominal and pelvic CT revealed pneumomediastinum in the posterior mediastinum (Fig. 2) and with minor extension into the superior peritoneum. (Fig. 3.) Decompressed small bowels were also noted in Figure 3.

Imaging revealed a pneumomediastinum and pleural effusion, which are indicative of a lower transmural esophageal tear. The patient was admitted to the ICU for sepsis and hypotension. Surgery was consulted for lower transmural esophageal tear and possible small bowel obstruction. (Fig. 3.) The patient was placed on broad-spectrum antibiotics, and a chest tube was placed on the left side. The esophageal stent was placed though an endoscopic procedure.

No small bowel obstruction was found. The diagnosis was actually an adynamic ileus secondary to the esophageal perforation, which was validated when the bowel movement spontaneously returned. The probable cause of esophageal rupture was combining anticholinergic and antipsychotic medications. The anticholinergic effect of these medications resulted in lower esophageal sphincter weakening and led to esophagitis. (Ann Intern Med 2000;133[3]:165.) Antipsychotic medication also causes retching and forceful vomiting. (Comprehensive Hospital Medicine: An Evidence-Based Approach. Philadelphia: Saunders Elsevier; 2007.) A combination of the two may have resulted in transmural tear of the lower esophagus, which is known as Boerhaave syndrome. (Ann Surg 1976;183[4]:401; http://bit.ly/2xVoJwn.) A surprising aspect of the case was that the patient displayed pain disproportionate to the severity of the problem. (Integr Physiol Behav Sci 1993;28[2]:118.)

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