Abstract Esophageal perforation is a rare but life-threatening condition which usually results from repeated vomiting or retching which leads to transmural rupture. Pleural effusion is commonly seen in these cases. We present a case of pleural effusion that was caused by spontaneous distal intramural esophageal tear without precedent vomiting or retching, leading to right sided pleural effusion. A 62-year old male with past medical history of alcohol use disorder and alcohol withdrawal syndrome, who was hospitalized for shock and was noted to have hyponatremia on labs after being found down at a gas station. He was managed for hyponatremia in the intensive care unit and was later transferred to the floor when stable. On day 8 of admission, he complained of chest pain and was noted to have large right sided pleural effusion. The effusion was noted to loculated and hence, a chest tube was placed. The pleural fluid analysis was remarkable for a pH of 7.04, amylase level of 266 IU/L, lipase level of 160 IU/L and lactate dehydrogenase level of 1826 IU/L; serum amylase level was 218 IU/L. A plain chest radiograph was also notable for extraluminal air along right side of distal esophagus. Given the findings of chest X-ray and the presence of amylase in pleural fluid, concern for esophageal perforation was raised. A CAT scan of the chest with oral contrast confirmed the findings confirmed the presence of a contained esophageal perforation. He underwent esophagogastroduodenoscopy (EGD) which revealed Mallory-Weiss tear in distal esophagus; an esophageal stent was placed. He was noted to have persistent effusion due to which he underwent VATS with decortication, which lead to resolution of the effusion. While esophageal rupture is an uncommon condition, pleural effusions are common in such patients; thoracic tear is associated with right sided effusion and the distal tear causes left sided ones. Pleural fluid analysis usually shows low pH and raised amylase level, with an elevated pleural fluid-to-serum amylase ratio. The interesting things to note in our patient were absence of antecedent symptoms, lack of full-thickness tear and a right sided pleural effusion (uncommon with distal esophageal perforation). The diagnosis was supported by pleural fluid finding of raised amylase level and a pleural fluid/serum amylase ratio of 1. Management includes broad-spectrum antibiotics, drainage of pleural effusion and repair of esophageal defect. While some cases may need surgical repair, endoscopic closure and concurrent drainage is associated with favorable outcomes. This abstract is funded by: None
Khalid et al. (Fri,) studied this question.