The patient became more hypoxic as his retching persisted; he was started on broad spectrum antibiotics and a nasogastric tube was placed. A CT scan of the abdomen and pelvis was performed and this revealed “pneumomediastinum with air around the distal esophagus, suggestive of an esophageal perforation and a left-sided pneumothorax.” With his hypoxia worsening and in his increasingly agitated state, the patient was taken into surgery for repair and chest tube placement after a consultation with General Surgery.
A full left thoracotomy was performed during which a 2.5cm tear in the distal esophagus was found as well as mediastinal fluid collection containing “hamburger, onions, and other green vomitus material”; two left-sided chest tubes and a gastric tube were then placed. The patient remained intubated through day 14 of his hospital stay. At day 17 he began tolerating liquids, and on day 23 he was finally discharged with a gastric tube in place.
Boerhaave syndrome, or spontaneous esophageal rupture, is a rare condition that “occurs as the result of barotrauma secondary to forceful retching and vomiting against a closed glottis.” Unlike Mallory-Weiss Syndrome, this condition “results in tears through all three layers of the esophagus, causing a chemical and bacterial mediastinitis.” Mortality rate is high with Boerhaave syndrome, ranging from 20–40% and if left untreated could approach 100%.
Diagnosis can be challenging as the classic triad (vomiting, chest pain, subcutaneous emphysema) may not present in all patients. Common symptoms may include dysphagia, pain, nausea, vomiting, fever, and dyspnea; although useful in aiding in diagnosis, chest X-ray may be normal in up to 12% of patients. While contrast esophagography may be the most reliable way to identify esophageal perforation, for some patients this may not be an option, so contrast-enhanced chest CT may help with diagnosis. Management of this condition includes “recognizing the diagnosis, resuscitation, prevention of further mediastinal contamination, broad-spectrum antibiotic therapy, and early surgical consultation.”
For this patient, ghost pepper ingestion led to forceful retching and vomiting resulting in esophageal rupture that could have easily been confused with discomfort after a large spicy meal. The authors conclude that “paramount to the success of treatment of a patient with Boerhaave syndrome is clinical suspicion and rapid diagnosis.”
Ann Arens, MD, Leila Ben-Youssef, MD, Sandra Hayashit, PharmD, and Craig Smollin, MD, Esophageal Rupture After Ghost Pepper Ingestion. The Journal of Emergency Medicine. doi.org/10.1016/j.jemermed.2016.05.061