A47-05 The Pleural Amylase Spilled the Beans: A Rare Case of Contained Esophageal Perforation Mimicking Parapneumonic Effusion

Abstract Introduction Esophageal perforation is a rare but life-threatening condition which usually results from repeated vomiting or retching eventually leading 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. Case A 62-year old male with past medical history of alcohol use disorder and alcohol withdrawal, 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. On day 8 of admission, he complained of chest pain and was found to have a loculated large right sided pleural effusion. A chest tube was placed. The pleural fluid analysis was remarkable for a pH of 7.04, amylase of 266 IU/L, lipase of 160 IU/L and lactate dehydrogenase of 1826 IU/L; serum amylase was 218 IU/L. A chest radiograph (CXR) was also notable for extraluminal air along right side of distal esophagus. Given the findings of CXR, the presence of amylase in pleural fluid and raised pleural fluid/serum amylase ratio, concern for esophageal perforation was raised. A CAT scan of the chest with oral contrast confirmed the presence of a contained esophageal perforation. He underwent esophagogastroduodenoscopy 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. Discussion While esophageal rupture is an uncommon condition, pleural effusions are common in such patients; a thoracic tear is associated with right sided effusion while a distal tear causes left sided one. Pleural fluid analysis usually shows low pH and raised amylase level, with a pleural fluid-to-serum amylase ratio 1. 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 findings 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