Severe chest pains may have rare cause

A patient with excruciating chest pain became an emergency. Dr Keith Barnard explains. I knew Mr Jackson from when he had an MI about three years ago, but had not seen him since. I was called to see him at the end of a Monday morning surgery.

His wife sounded worried because he had been complaining of indigestion, had vomited and did not feel he could get to the surgery.

He was in bed when I arrived and looked very pale. He said he had had indigestion since the Saturday night, when he had attended a friend’s silver wedding party and had over-indulged. That morning he felt nauseous, then vomited and retched for some minutes.

Since his wife called me, he had vomited again and was developing severe chest pain that radiated through to his back, but not to his arms. His BP was normal, as were the heart sounds, with a pulse rate of about 100 per minute. I could find nothing else wrong and was thinking of doing an ECG when he went pale and sweaty and said the pain was increasing. He was clearly in agony.

I had been caught out before by an MI in the guise of indigestion and, as the ambulance station was at the end of the road, I admitted him immediately via a 999 call.

I forgot to give him aspirin before he left, which was just as well because I was surprised to receive a call later that day from the surgical registrar, not, as I would have expected, the coronary care unit.

The surgeon wanted to know a little more about Mr Jackson’s medical background and was he was obviously quite excited to have seen a rare case that had been successfully diagnosed and treated.

My patient had Boerhaave syndrome; I had no idea what this was. The registrar explained that it was spontaneous transmural rupture of the oesophagus and happens when forceful vomiting occurs against a closed cricopharyngeal sphincter.

Boerhaave syndrome

The syndrome was first described by Herman Boerhaave in 1724.

Apparently it has also been reported after Valsalva-like manoeuvres such as in childbirth, straining at stool and heavy lifting.

The tear is most commonly found at the left posterolateral wall of the lower third of the oesophagus, 2–3cm before the stomach.

In Mr Jackson’s case the admitting medical house officer had noticed a strange crunching sound when auscultating the chest — this is the Hamman sign.

An X-ray showed air in the mediastinum and a left pleural effusion. Undiagnosed cases quickly proceed to septic shock, cardiovascular collapse and death.

Eight days later Mr Jackson recovered from his thoracotomy and repair of the oesophageal tear and had his chest drains removed.

His heart stood up to the strain well and he was came to see me in the surgery three weeks later. 

Dr Barnard is a former GP in Fareham, Hampshire

Lessons learnt

  • Spontaneous transmural oesophageal rupture is a very rare occurrence and is a result of severe vomiting.
  • It occurs most frequently in middle-aged men with recent dietary and alcohol overindulgence, who develop severe chest pain after repeated retching and vomiting.
  • Surgical emphysema may be present.
  • The differential diagnosis includes pulmonary embolism, acute myocardial infarction, aortic dissection, perforated ulcer, acute pancreatitis or acute cholecystitis and pneumothorax.
  • Not to be confused with the Mallory-Weiss syndrome, which is haematemesis from a tear in the mucosa of the oesophagus, also brought on by vomiting.

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