What is the most common location for pneumomediastinum to occur in a patient with severe pleuritic chest pain and a history of forceful vomiting, as evidenced by chest X-ray?

From the Guidelines

The most common location for esophageal perforation in this case is the distal posterolateral esophagus, specifically the left posterolateral wall just above the gastroesophageal junction. This condition, known as Boerhaave syndrome, typically occurs after forceful vomiting which creates a sudden increase in intraluminal esophageal pressure, as seen in this patient who presented with severe pleuritic chest pain radiating to his back after several hours of forceful vomiting 1. The distal esophagus is particularly vulnerable because it has less muscular support and experiences higher pressure during vomiting. The left posterolateral aspect is anatomically the weakest point of the distal esophagus.

Key Points to Consider

• The patient's presentation with severe chest pain radiating to the back after forceful vomiting, along with pneumomediastinum on chest X-ray, is classic for this condition 1.
• Boerhaave syndrome is a surgical emergency with high mortality if not promptly diagnosed and treated, typically requiring surgical repair, broad-spectrum antibiotics, and supportive care to manage this full-thickness esophageal tear.
• Contrast-enhanced computed tomography (CT) and CT esophagography is the imaging examination of choice in patients with suspicion of esophageal perforation (EP), as it is highly sensitive (92–100%) in detecting EP and helps to assess extension to adjacent structures 1.
• Indirect signs of esophageal injury can also be seen on a plain chest radiograph, including pleural effusion, pneumomediastinum, subcutaneous emphysema, hydrothorax, pneumothorax, and collapse of the lung 1.

From the Research

Pneumomediastinum Location

The most common location for pneumomediastinum to occur is not explicitly stated in the provided studies. However, the studies do provide information on the locations of esophageal ruptures, which can be associated with pneumomediastinum.

• The distal esophagus is a common location for esophageal ruptures, with one study mentioning that spontaneous esophageal rupture due to vomiting is also known as Boerhaave's syndrome, which typically occurs in the distal esophagus 2.
• Another study mentions that Boerhaave's syndrome, or postemetic rupture of the esophagus, represents one of several etiologies of esophageal perforation, but does not specify the exact location 3.
• A study on eosinophilic esophagitis (EoE) and Boerhaave's syndrome found that all four patients presented with a triad of vomiting, chest pain, and pneumomediastinum, but does not provide information on the specific location of the rupture 4.
• The other studies do not provide information on the specific location of pneumomediastinum or esophageal ruptures 5, 6.

Esophageal Rupture Locations

While the studies do not provide a clear answer to the question of the most common location for pneumomediastinum, they do provide information on the locations of esophageal ruptures.

• The distal esophagus is a common location for esophageal ruptures, with one study mentioning that Boerhaave's syndrome typically occurs in the distal esophagus 2.
• The options provided in the question include:
  • Distal anteromedial esophagus
  • Distal posterolateral esophagus
  • Gastroesophageal junction
  • Upper esophageal sphincter However, the studies do not provide enough information to determine which of these locations is the most common for pneumomediastinum or esophageal ruptures.