Boerhaave Syndrome With Alkaline Pleural Effusion Kelechi Okoli

Boerhaave Syndrome With Alkaline Pleural Effusion Kelechi Okoli, MD; Vamsee Marina, MD; Hussam Elkambergy, MD; Geetali Mohan, MD; Veejay Mahajan, MD OHIO THORACIC SOCIETY 57 TH ANNUAL CONFERENCE 7 - 8 SEPTEMBER, 2007

Pleural Fluid p. H in Esophageal Rupture �Gastric acid reflux 1? �Bacterial metabolism? �Neutrophil metabolism 2? ◦ Only elimination of neutrophils prevented fall in p. H in experimental esophageal rupture 1. Abbott OA, Mansour KA, Logan WD, et al: Atraumatic so-called "spontaneous" rupture of the esophagus. J Thorac Cardiovasc Surg 59: 6742, 1970 2. Good JT Jr, Antony VB, Reller LB, Maulitz RM, Sahn SA. The pathogenesis of the low pleural fluid p. H in esophageal rupture. Am Rev Respir Dis. 1983 Jun; 127(6): 702 -4

HPI � 41 year-old type 1 diabetic �Two days of nausea and vomiting �PMH: ESRD, CVA, PE �Uremia. Hyperkalemia. DKA �Hemodialysis and insulin �Resolution of clinical and biochemical abnormalities

HPI �On fifth hospital day, he vomited �Acute dyspnea �BP 89/30 mm. Hg; HR 128/min; RR 34/min; Sa. O 2 83%; Temp 36. 6 o. C �Absent breath sounds over left hemithorax �Portable CXR obtained

Intervention �Left tube thoracostomy �Left lung re-expansion �Persistent air leak �Non-ionic contrast esophagogram

Pleural Fluid �p. H Blood – 7. 51 �LDH – 184 IU/L. p. H – 7. 28 �Protein – 2. 8 g/d. L. LDH – 196 IU/L �Amylase – 2400 U/L. Protein – 3. 9 g/d. L �No WBC seen. WBC – 17. 8 x 109 �Oral flora, Klebsiella, Haemophilus 1. Corning p. H meter

Outcome �Left thoracotomy and decortication � 2 cm perforation in left posterolateral esophageal wall 3 cm proximal to EGJ �Complicated post-operative course �Ventilator dependent �Expired in palliative medicine unit

Conclusion �Current case supports neutrophil metabolism �Temporal relationship between symptom onset and pleural fluid sampling should be considered when esophageal rupture is suspected

Abstract