Esophageal Rupture: Diagnosis by Pleural Fluid pH

Effect of Thoracentesis on Arterial Oxygen Tension

“…The hydrogen ion activity and Pco, are high in hemorrhagic [11] and empyema [17,23] fluids and significantly lower in effusions resulting from cardiac and malignant disease [11,13,14,19]. A pleural fluid pH below 6.0 is pathognomon ic of esophageal rupture [9], In addition, we have utilized pleural fluid pH and Pco2 measurements in effusions of several days duration to differentiate between a true 'bloody tap' and an artifact associated with traumatic aspiration (pH > 7.25; Pco2 < 60 mm Hg).…”

“…While the Po2 of hemorrhagic and empyema fluids have been observed to be particularly low [22,23] and perhaps also lower than ex pected in malignant effusions [11,22,23] the Po2 of pleural fluid samples have been reported to reflect venous oxygen ten sions in a nonspecific manner [9]. In con trast to these previous findings in pleural fluid and in other tissue gas pockets [3,10,26], we have observed high Po2 levels suggesting equilibration with alveolar gas in occasional patients with congestive heart failure and in l patient with fibrothorax.…”

Unusual Presentation of an Esophagopleural Fistula in a Patient With Severe Esophagitis: Blunt Trauma or Iatrogenic?

“…The pH of 5.56 in the pleural fluid was another clue to the diagnosis because a pleural fluid pH of 5–6 has been described in cases of esophageal rupture. 5 A pH less than 7 is also associated with empyema and parapneumonic effusions, but in this condition, the glucose level is usually low. The pleural fluid glucose in our case was 1,088 mg/dL, most likely from contamination of the pleural fluid with enteric contents from the patient's oral intake.…”

Spontaneous Esophagopleural Fistula in A High Risk Individual (Trumpet Blower)

“…5 A high index of suspicion is necessary to diagnose spontaneous esophageal perforation with resultant complications:-A) excruciating retrosternal chest pain with a sensation of tearing or bursting in the lower part of chest or the epigastrium, often unrelieved by opiates 6 B) may have preceding history of vomiting, dysphagia or associated with hemoptysis, dyspnea C) clinically subcutaneous emphysema that appear first in the suprasternal notch suggest esophageal perforation [6] D) chest radiograph revealing pleural effusion (60%) frequently hydropneumothorax (25% cases) [7] particularly when the mediastinal pleura rupture, diffuse mediastinal widening with air visible within the mediastinal compartments and soft tissues (hallmark sign) 3,5 E) chest CT scan showing paraesophageal air tracks 8 F) characteristic pleural fluid picture revealing high amylase level (best indicator of esophageal rupture), mainly salivary variant rather than pancreatic variety 9 , low pH (pH< 7.00 suggest increased likelihood of rupture, whereas pH<6.00 is highly suggestive of esophageal rupture [10] ), presence of squamous epithelial cells (by wright's stain) [11] , presence of ingested food particles (virtually diagnostic) and multiple pathogens on smear or culture (polymicrobial empyema particularly when the daily pleural fluid output is high) 3 However for confirmation, following imaging modalities may be contemplated-A) contrast study of the esophagus (with barium or gastrograffin or meglumine or ioxaglate sodium) in decubitus position which is positive in approximately 85% of patients [12] demonstrating the actual site of perforation and its interconnecting cavities B) chest CT with oral and intravenous contrast showing extravasation of orally ingested contrast material into the periesophageal or pleural space (pathognomonic sign) [13] extraluminal air and focal thickening or ballooning and thinning of the esophageal wall at the site of perforation C) upper gastrointestinal (g.i.) endoscopy D) passage of orally ingested colored dye/ contrast agent (sterile methylene blue used in our case) in the intercostals drainage bag may be an effective intervention to stamp the diagnosis.…”