A 17-year-old girl presents to the emergency department with excruciating retrosternal chest pain. She reports that the chest pain began abruptly less than two hours ago. There was no preceding trauma. Her past medical history is significant for bulimia nervosa but is otherwise unremarkable. She denies tobacco, alcohol, or drug use. Vital signs reveal tachycardia and hypotension.
A) Chest wall crepitus on physical examination
Considering this patient’s history of bulimia nervosa and history of abrupt onset of excruciating retrosternal chest pain, this patient most likely is suffering from Boerhaave syndrome as a result of self-induced vomiting. Forceful vomiting can lead to esophageal rupture secondary to increased intraesophageal pressue. In Boerhaave syndrome, physical examination may be significant for chest wall crepitus due to subcutaneous emphysema. Boerhaave syndrome leads to chemical mediastinitis due to contamination of the mediastinal cavity with gastric contents.
Answer choice B: Elevated troponin, is incorrect. This young patient does not have risk factors for or a history suggestive of coronary artery disease, so an elevated troponin would not be expected.
Answer choice C: Increased gastric acidity, is incorrect. Though this patient has a history that suggests self-induced vomiting or other purging or fasting behaviors, increased gastric acidity results in gastritits, esophagitis, or gastroesophageal reflux disease. This patient’s history of sudden-onset excruciating chest pain is not consistent with increased gastric acidity.
Answer choice D: Pulmonary infiltrates on chest x-ray, is incorrect. Pulmonary infiltrates seen on chest x-ray is suggestive of an infectious or inflammatory process and would not result in sudden-onset severe chest pain.
Answer choice E: ST-segment elevations on electrocardiogram, is incorrect. ST-segment elevations may occur in the setting of myocardial infarction, pericarditis, and other processes but would not be expected in the setting of Boerhaave syndrome.
Key Learning Point
Chest wall crepitus due to subcutaneous emphysema may be seen in patients with Boerhaave syndrome. Other clinical manifestations include mediastinal crackling with each heartbeat (due to mediastinal emphysema) heard on auscultation, fever, tachypnea, tachycardia, and hypotension.
