Ryan came into the surgery in great distress, and was put in to see me ahead of my other patients by our worried practice nurse.
He was pale, sweating and in obvious pain, and seemed almost on the point of collapse. I knew this was no act - Ryan was a tough lad of 24, who I only knew from treatment of a football injury some months ago.
He played for a pub team and I had the impression that they were a hard-drinking bunch. I asked him what was going on.
'It's my chest, doc,' he said, clutching his hand to his breastbone, then he went on to explain the profuse vomiting he had been experiencing for the past few days. Further questioning elicited that this had been going on for about three days, but there was no blood in the vomit or in the stools.
'And then last night,' Ryan volunteered, similes coming thick and fast, 'I was sick as a dog again and this pain started, and now I feel as weak as a kitten.'
I asked what might have brought this on, and Ryan looked sheepish. 'Well,' he explained, 'we got through to the league cup final last weekend and I had a fair bit to drink.'
A 'fair bit' turned out to be over 20 cans of strong lager in the space of one night.
Examination showed Ryan to be pale, distressed and agitated, with nicotine-stained fingers, a pulse of 120 beats per minute and a BP of 110/60 mmHg. His temperature was raised at 38 degsC. There was some tenderness over his upper chest and neck, but the lungs sounded clear, the heart sounds were normal and the abdomen soft.
As he was standing to leave the examination couch, he grabbed onto me and nearly collapsed. I dialled straight through to the ambulance service and in 10 minutes he was on his way to hospital, sirens blaring and lights flashing.
I was thinking of severe dehydration and maybe Mallory-Weiss syndrome, but it was worse than that. When the report came back from the hospital, it explained that closer questioning of Ryan revealed he had vomited over 30 times in the previous 24 hours, and the result was a ruptured oesophagus.
He was found to have a raised white cell count, deranged electrolytes due to dehydration, and perhaps remarkably, normal LFTs. A chest X-ray showed air along the left heart border and the aortic arch, a key diagnostic sign. A CT scan confirmed free air in the mediastinum and pericardial sac.
An oesophageal swallow with a water-soluble contrast medium demonstrated the site of the small perforation. Although not used in this case, endoscopy is also an investigative option.
Spontaneous rupture of the oesophagus is a rare event, accounting for only 16 per cent of cases of traumatic rupture, and it is life threatening.
Intervention within 24 hours has a survival rate of 75 per cent, but this drops to as low as 11 per cent if diagnosis and treatment are delayed by 48 hours. The condition is sometimes referred to as Boerhaave syndrome.
It is characterised by complete rupture of the oesophageal wall, and the theory is that it results from forceful vomiting when a sudden increase in intraluminal pressure occurs. This happens due to uncoordinated vomiting when the pylorus is closed, the diaphragm contracts vigorously, and the cricopharyngeal muscle is tightly contracted. Haematemesis is not normally a feature and can help distinguish oesophageal rupture from Mallory-Weiss syndrome.
Ryan's danger was from extensive sepsis leading to multi-organ failure. Although various surgical techniques to repair the perforation are available, Ryan was treated conservatively with IV fluid resuscitation, nasogastric suction, broad-spectrum antibiotics and analgesia. Within 10 days he was back home, and was playing football again a month later.
Ryan swore he would not binge drink again, but I can only hope he remembers this if his team win that league cup.
- Dr Barnard is a former GP in Fareham, Hampshire.