Spontaneous esophageal rupture: A frequently missed diagnosis

The objective of this study was to determine the diagnostic features of spo ntaneous esophageal rupture and compare them with those traditionally appli ed in making this diagnosis. A retrospective 15-year chart review was perfo rmed on all cases listing esophageal rupture as a diagnosis. Only those cas es diagnosed by contrast studies or direct visual confirmation were include d. Facets of the history, physical examination, laboratory results, and X-r ay procedures were examined and compared with the "classic" presentation of this diagnosis as noted in current medical texts. Fourteen cases of confir med esophageal rupture were found. Only a small minority of cases presented in a fashion resembling a classic case. Esophageal rupture was the admitti ng diagnosis in 29 per cent of the cases. Laboratory values associated with esophageal rupture included elevated white blood cell count and hypoxia. T he chest X-ray was abnormal in all but one patient, with findings of pneumo thorax and/or pleural effusion in the majority. We conclude that reliance o n classic findings will lead to misdiagnosis in the vast majority of cases presenting to the Emergency Department. Conversely, toxic appearance, pleur al effusion, pneumothorax, elevated white blood cell count, azotemia, and h ypoxia are all positively associated with this disease. In toxic-appearing patients with pleural effusions and/or pneumothoraces, spontaneous esophage al rupture should be considered.