Biliary contents in the chest drain tube: a finding not to ignore

Boerhaave Syndrome Presenting as Tension Pneumothorax

“…First described in 1724, Boerhaave syndrome is spontaneous transmural rupture of the esophagus classically identified by the Mackler triad of subcutaneous emphysema, vomiting, and chest pain. [4][5][6][7][8] It carries a high mortality of 20% to 30% at diagnosis, with linear increase in mortality for subsequent delay of 2 to 5 days. 5 The rupture typically occurs in the left supradiaphragmatic portion of the esophagus due to thinning of the longitudinal and circular musculature and lack of adjacent support.…”

“…Presentations are frequently atypical and nonspecific, typically involving males (75%-80%) in the 40-to 60-year age-group. [6][7][8] Chest pain is reported to be the most common feature, followed by retching, vomiting, and dyspnea. 3,9 Rarely, hemodynamic compromise maybe noted following development of pneumomediastinum.…”

“…3,4 Typically, pleural fluid shows acidosis (pH <6.0), high amylase content, salivary squamous cells, polymicrobial gram stain or culture, and rarely, intact food particles and biliary contents. [7][8][9][10] However, prior fasting and use of gastric acid-suppressive medications frequently confound these findings, presenting as benign pleural effusions.…”

A Rare Case of Boerhaave Syndrome Presenting with Right Tension Pneumothorax and Review of the Literature

“…Complicating an already difficult clinical picture, the false negative rate of contrast swallow study for esophageal injury is reported at 10%-25%, though this may be improved with additional testing with insoluble contrast such as thin barium [16]. There are also reports of the use of presence of visible food particles from thorascopic drainage to diagnose Boerhaave syndrome [15,17]. Our case provides further support for careful clinical inspection of chest tube output to detect biliary or gastric contents as a fast and efficient way to clinically diagnose Boerhaave syndrome in patients without obvious external trauma, or in those for whom oral contrast enhanced imaging in not feasible.…”