Differential Diagnosis
- Single most likely diagnosis
- Esophageal perforation: This is the most likely cause of the symptoms given the history of recent endoscopy and dilatation of an esophageal stricture, followed by severe chest pain, vomiting blood, and signs of sepsis (fever, tachycardia). The presence of crepitus in the neck, which indicates subcutaneous emphysema, is a classic sign of esophageal perforation.
- Other Likely diagnoses
- Bleeding from erosive esophagitis: Although less likely given the specific context of recent esophageal dilatation, bleeding from erosive esophagitis could explain the hematemesis. However, it would not typically cause crepitus or the severity of pain described.
- Mallory-Weiss syndrome: This condition involves tears in the mucous membrane or lining of the lower end of the esophagus, where it connects to the stomach, often due to intense or prolonged vomiting. While it could explain the hematemesis, it doesn't fully account for the other symptoms like crepitus and severe chest pain.
- Perforated gastric ulcer: Although this could cause severe abdominal pain and potentially lead to sepsis, it doesn't directly explain the chest pain or crepitus in the neck as well as esophageal perforation does.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Myocardial infarction: While the presentation is not typical for myocardial infarction (MI), especially given the context of recent endoscopy, MI can sometimes present atypically, especially in women or the elderly. The severe chest pain and tachycardia could be indicative of an MI, making it crucial not to miss this diagnosis.
- Rare diagnoses
- Aortic dissection: This is a rare but life-threatening condition that could present with severe chest pain. However, it is less directly related to the recent endoscopy and dilatation procedure compared to esophageal perforation.
- Pneumomediastinum from other causes: While the crepitus suggests air in the soft tissues, which could be due to pneumomediastinum, other causes (like lung barotrauma) are less likely given the context of recent esophageal manipulation.