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Chest Pain and Hematemesis in a 48-year-old Man


Two hours earlier the patient had vomited to dislodge food stuck in his throat. This had been effective in the past but had never produced blood. Chest and epigastric pain worsened when he lay down.

Pneumomediastinum caused by Boerhaave syndrome

Chest x-ray, PA view (click to enlarge)

A 48-year-old man presents to the emergency department with chest pain and hematemesis. History is significant for hiatal hernia, acid reflux, and a single esophageal dilatation 15 years ago for an impacted food bolus. He states that about 2 hours ago he got a piece of steak stuck in his throat. He couldn’t get it down so he stuck his finger down his throat and successfully induced vomiting. He states he has done this before and afterwards has felt better; this time, however, he vomited blood, which has never happened before.  Since the vomiting episode, there has been no further bleeding but he has been having pain in his chest and epigastric area which is worse if he lies down. This is also unusual for him. He denies any trouble breathing, melena, prior liver disease or heart disease, or other concerns.

On physical examination he is alert and in moderate distress, standing upright next to the bed.  Vital signs are normal except for his blood pressure which is elevated at 168/99 mm Hg. Head and neck examinations demonstrate a moist oropharynx without blood; he is handling his secretions without difficulty. His lungs are clear without wheezing or rales and his heart is regular without any abnormal sounds. His abdomen is soft and non-tender. The rest of the exam also is normal.

A screening ECG is performed to evaluate the patient’s chest pain and shows a normal sinus rhythm at a rate of 71 beats/min with nonspecific ST changes. Result of blood tests including a CBC, metabolic panel, troponin, LFTs, and lipase are all essentially normal as well. His chest x-ray is shown in the Figure, above.

What, if any, abnormal findings do you note?

What’s your diagnosis?

Please leave your comments below; click here for answer and discussion.

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