DrPak
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A 42-year-old man comes to the physician because of a 3-month history of substernal chest pain after every meal. He has chronic alcoholism and a long history of heartburn. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter (LES). Multiple biopsies were taken. 4 hours later he is complaining of worsening substernal pain radiating to the back, left chest pain, and shortness of breath. His temperature is 37.1C(98.9F), blood pressure is 110/70 mm Hg, pulse is 140/min, and respirations are 34/min. An x-ray film of the chest shows minimal left pleural effusion. Which of the following is the most appropriate next step in management?
(A) Repeat the endoscopy
(B) Contrast study of the esophagus
(C) Check serum amylase and lipase level
(D) Wait until the pathologic diagnosis is ready
(E) Thoracocentesis
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| oasis
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contrast study of esophagus to diagnose iatrogenic rupture
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| DrPak
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What is the significance of the pleural effusion?
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| robin082006
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iatrogenic esophageal perforation-->B
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| fox
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Pleural effusion can develop in case of esophageal rupture. This is a clear case of iatrogenic rupture. But there is no point of doing barium swallow. You would probably wanna do an endoscopy & decide further Mx after assesing the size of perforation
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| chemamr
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water soluble contrast study
B
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| DrPak
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Yes, the answer is B for the reasons stated by the others. A scope is not the way to go in perforations because you could end up pushing the scope into the mediastinum.
This question threw me off because of the pleural effusion. If the perforations leads to mediastinitis, why would there be pleural effusion? It's not as if the pleura had been penetrated.
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| yu
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DrPak wrote:
Yes, the answer is B for the reasons stated by the others. A scope is not the way to go in perforations because you could end up pushing the scope into the mediastinum.
This question threw me off because of the pleural effusion. If the perforations leads to mediastinitis, why would there be pleural effusion? It's not as if the pleura had been penetrated.
Did you notice pleural effusion is MINIMAL, that means the effusion level is near normal. A very good distractor, also got me.
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| DrPak
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yu wrote:
Did you notice pleural effusion is MINIMAL, that means the effusion level is near normal. A very good distractor, also got me.
Aaahhh... yes!
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| may_u_b_blessed
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would such a MINIMAL pleural effusion cause sucha severe clinical deterioration??? why cant we think of acute pancreatitis cos of the history of chronic alcoholism?
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| DrPak
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The minimal pleural effusion is not part of the problem, it's just an incidental finding. Acute pancreatitis is possible, but the question is telling you he's getting worse 4 hours after an endoscopic proceedure, which is typical for instrumental perforation.
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| may_u_b_blessed
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ah ok i get it....thanks
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| Aashi
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Dear Dr pak..
Pleural effusions following a esophageal rupture is a late finding,and is a SIGN of eso.rupture..if it was pancreatitis causing this effusion, the hx shld have mentioned atleast one symptom related to pancreatitis, so it is better that WE DONT ASSUME, that the pt has subtle s/s of pancreattis, which is really not the case here, and this HX is crystal clear for eso.rupture and all the s/s mentioned are directly attributable to eso.rupture and nothin is INCIDENTAL..
The Etiology behind behind this pleural effusion might be the leakage of swallowed saliva in to the pleural space through the perforated esophagus and this could explain y it is minimal, and thats y if u do a pleural fluid analysis on this effusion, salivary amylase is found to be high and the Ph is low..Pleural fluid amylase levels can be elevated in acute pancreatitis, pancreatic pseudocyst, esophageal rupture, malignancy, and ruptured ectopic pregnancy.
GL
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| DrPak
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Thanks Aashi, that clears things up wonderfully.
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