What is the next step in management for a patient with severe chest pain after repeated vomiting and a small left pleural effusion on chest x-ray?

Management of Severe Chest Pain After Repeated Vomiting with Small Left Pleural Effusion

The next step in management is (d) administer Gastrografin swallow test to confirm or exclude esophageal perforation (Boerhaave syndrome), which is a life-threatening emergency requiring immediate diagnosis and treatment.

Clinical Reasoning

This presentation is highly suspicious for Boerhaave syndrome (spontaneous esophageal perforation):

• Classic triad: Severe chest pain following repeated vomiting in an alcoholic patient 1
• Left-sided pleural effusion: Esophageal perforation typically causes left-sided effusion due to the anatomical position of the distal esophagus 1
• High mortality risk: Delayed diagnosis significantly increases mortality, making rapid confirmation essential 1

Diagnostic Algorithm

Step 1: Contrast Esophagography (Gastrografin Swallow)

• Water-soluble contrast (Gastrografin) is the initial diagnostic test of choice for suspected esophageal perforation 1
• CT scan with oral contrast is more sensitive than conventional contrast studies and can detect small perforations, pneumomediastinum, and pleural effusions 1
• Chest X-ray alone is insufficient as it may appear normal or show only pleural effusion, missing the perforation 1

Step 2: If Perforation Confirmed

• Immediate surgical consultation is mandatory as this is a medical emergency 1
• Management options include surgical repair, endoscopic stent placement, or conservative management depending on perforation characteristics 1
• Broad-spectrum antibiotics should be initiated immediately 1
• NPO status with nasogastric tube for gastric decompression 1
• Chest tube placement if significant pleural contamination is present 1

Why Other Options Are Incorrect

Option (a) - Cardiac Workup

• While cardiac causes must be considered in chest pain, the temporal relationship with vomiting and left pleural effusion makes esophageal perforation more likely 2
• Delaying diagnosis of Boerhaave syndrome to pursue cardiac evaluation increases mortality 1

Option (b) - Nasogastric Tube and Observation

• Blind nasogastric tube insertion could worsen an esophageal perforation if present 1
• Simple observation is dangerous when perforation is suspected, as mediastinitis develops rapidly 1

Option (c) - Immediate Chest Tube and Antibiotics

• Placing a chest tube before confirming the diagnosis may be premature 1
• Diagnosis must be established first to guide appropriate definitive management 1

Option (e) - Upper Endoscopy

• Endoscopy carries risk of extending the perforation by insufflation 1
• Contrast studies are safer and more appropriate as the initial diagnostic test 1

Critical Pitfalls to Avoid

• Do not delay imaging when esophageal perforation is suspected—persistent chest pain after vomiting mandates immediate investigation 1
• Suspect perforation when patients develop pain, breathlessness, fever, or tachycardia after procedures or vomiting 1
• Normal chest X-ray does not exclude perforation—CT with oral contrast should be performed if clinical suspicion remains high 1
• Time is critical: Mortality increases significantly with delays beyond 24 hours from perforation 1