Morning Report

Morning Report: Atypical Cause of Chest Pain

Resident Presenter: Molly Malone PGY1

Topic: Atypical Cause of Chest Pain


Patient is a 70 year old female with a PMHx significant for HTN, HLD, COPD, diaphragmatic hernia and anxiety presenting to the ED for chest pain x5 days. Pt reports the pain is located in her b/l chest and radiates to her b/l back. She categorizes it as 8/10, persistent lower rib cage pain, sharp in nature, and exacerbated with deep breathing. Pt endorses mild relief with Advil and 2 episodes of emesis yesterday. Pt denies, SOB, cough, abdominal pain, nausea, or fever.

Initial vitals: T: 36.4°C | HR: 101 | BP: 100/68 | RR: 16 | O2 Sat: 97% RA

Pt was in NAD had an unkempt odor about her and physical exam was unremarkable except for tachycardia and b/l chest tenderness.

Initial plan was for ACS work up including EKG, CXR, labs, Trops. When these came back negative the work up was extended to include PE. The patient received a CT-PE and was found to have:

“Mural thickening and adjacent stranding of the mid to distal esophagus. Within the esophagus just proximal to the GE junction there is a questioned focus of intramural air possibly reflecting a Mallory-Weiss tear. No evidence of mediastinal emphysema”

Learning Points:

  • Atypical causes of chest pain: Mallory-Weiss tear, Boerhaave Syndrome, Diaphragmatic Hernia
  • Upright CXR, Esophogram, CT-chest
  • Treatment for Boerhaave: Conservative and Operative
    • 1st call to CT surgery
    • Conservative Management – Disruption contained in the mediastinum or between the mediastinum and visceral lung pleura; drainage of the cavity back into the esophagus; minimal symptoms; and minimal signs of clinical sepsis
    • Volume resuscitation – IVF and broad spectrum antibiotics to include anaerobes
  • Toby Factor: effusion usually occur and are seen in the LEFT plural cavity


See comment in PubMed Commons below: Spontaneous esophageal rupture: a frequently missed diagnosis, Am Surg. 1999 May;65(5):449-52.

A case of rapid diagnosis of Boerhaave syndrome by thoracic drainage: J Emerg Med. 2012 Dec;43(6):e419-23. doi: 10.1016/j.jemermed.2011.05.079. Epub 2011 Dec 22.

Against all odds. Conservative management of Boerhaave’s syndrome: BMJ Case Rep. 2014 May 21;2014. pii: bcr2013200485. doi: 10.1136/bcr-2013-200485.


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