Question

A 56-year-old man presents to the emergency department with severe epigastric pain that began an hour prior to presentation. He describes the pain as sharp, 10/10 in severity, and radiating to the back. Swallowing worsens the pain and causes him to cough. Before the pain started, he had been vomiting multiple times per day for the past week. The emesis was yellow and he denied ever seeing blood. Medical history is significant for poorly controlled hypertension, type II diabetes, alcohol use disorder, and 2 prior hospitalizations for acute pancreatitis. He smokes 1 pack of cigarettes per day for the last 35 years, denies illicit drug use, and drinks 3 pints of vodka per day. On physical exam, there is mediastinal crackling in synchrony with cardiac contraction on cardiac auscultation in the left lateral decubitus position. Laboratory testing is significant for leukocytosis. Which of the following is most likely the cause of this patient's symptoms?

a. Coronary artery occlusion
b. Dissection of the aorta
c. Inflammation of the pancreas
d. Ulcerative changes in the gastric mucosa
e. Transmural esophageal rupture

Answer 1

The most likely cause of the man's symptoms, given the severe epigastric pain, vomiting, and mediastinal crackles, is a transmural esophageal rupture.

Step-by-step explanation:

The symptoms described by the 56-year-old man, including severe epigastric pain radiating to the back, exacerbated by swallowing and cough, along with a history of vomiting and prior hospitalizations for acute pancreatitis, leans towards a diagnosis of transmural esophageal rupture (option e). This condition is also known as Boerhaave syndrome and is consistent with the mediastinal crackles heard during physical examination, which may be indicative of air escaping from the esophagus into the mediastinum (mediastinal emphysema). While the other options are differential diagnoses for chest or abdominal pain, the specific symptoms and clinical signs provided are most characteristic of an esophageal rupture.