Structural Abnormalities
MALLORY-WEISSTEAR
Partial esophageal tear, usually due to retching or vomiting; longitudinal
mucosal tears seen at the gastroesophageal junction
SYMPTOMS
Hematemesis after forceful retching
EXAM
Rule out crepitus of the neck or peritonitis, which would suggest complete
esophageal perforation.
DIFFERENTIAL
Esophagitis, Boerhaaeve syndrome, peptic ulcer disease
DIAGNOSIS
History or endoscopy
TREATMENT
■ May cause upper GI Bleed (see “GI Bleeding” for treatment)
■ Usually no treatment required
BOERHAAVESYNDROME
This is a postemetic perforation. Ten percentof cases involve patients with
underlying pathology that causes leakage of nonsterile substances into the medi-
astinum. Boerhaave’s is a cause of rapid overwhelming sepsis. Iatrogenic perfora-
tions account for 80% of cases of esophageal perforation. Rupture of all layers of
the esophageal wall is possible, most commonly on the left posterolateral aspect.
SYMPTOMS
■ Most common presentation is chest or midepigastric pain that radiates to
the neck and occasionally the back.
■ Most reliable presentation is pleuritic pain in the esophageal region that is
worsened by neck flexion and swallowing.
■ Often associated with pneumothorax or hydrothorax
■ Mediastinal crunch (Hamman sign) may be heard on auscultation of the
heart.
■ Fever or shock may be present as well.
DIAGNOSIS
■ Plain CXR and/or soft-tissue lateral neck XR reveals mediastinal air. Other
findings include subcutaneous emphysema, left-sided pleural effusion,
pneumothorax, and widened mediastinum.
■ An esophagram using water soluble contrast and EGD are the definitive
studies to diagnose and locate a perforation.
■ CT scan may show mediastinal air.
■ Thoracentesis will show high amylase level secondary to esophageal con-
tents in the pleural space.
ABDOMINAL AND GASTROINTESTINALEMERGENCIES