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65-year-old, mentally impaired white female with a history of steroid-dependent reactive airway disease as well as type 2 diabetes mellitus who presented with a several day history of nausea and retching followed by abdominal pain and shortness of breath. She is admitted to the intensive care unit prior to surgery.
PE. She had blood pressure of 126/66 pulse 105/m and temperature of 100.8 F. HEENT: Head normocephalic, nasogastric tube in place, orally intubated. NECK: Supple, LUNGS: decreased breathy sounds on the left, HEART: regular and tachycardic, ABDOMEN: distended with gardening, bowel sounds decreased, EXTREMITIES: Warm and well perfused., no edema.
Her chest X-ray on admission revealed left pleural effusion:
CT scan of the chest and abdomen was done and revealed moderate sized left sided pleural effusion, left sided pneumothorax and air present in the mediastinum outlining the distal esophagus and extending to the level of GE junction:
Esophagogram showed moderate amount of retained food within the distal esophagus with free perforation into the left pleural space:
The patient was taken to surgery where on surgical intervention, she was found to have food, pills, and saliva in the left chest cavity. She also had a 3 cm distal tear in the esophagus. This was closed primarily, large drainage tubes were placed. She remained hemodynamically stable, intubated, and mechanically ventilated. The patient also had a feeding gastrostomy placed intraoperatively. Post operative chest X-ray is shown:
Patient spent an uneventful ICU course, she was extubated after 7 days and later discharge to the floor in a stable condition.
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