Which finding is most characteristic of esophageal perforation after a recent endoscopy or forceful vomiting?

Which finding is most characteristic of esophageal perforation after a recent endoscopy or forceful vomiting?

• A. Retrosternal chest pain with crepitus due to pneumomediastinum
• B. Epigastric pain relieved by meals
• C. Hematemesis without chest symptoms
• D. No respiratory symptoms

Answer: (A)

A tear in the esophagus after vomiting or recent instrumentation allows air to escape into the mediastinum, causing pneumomediastinum. This irritation from the mediastinal air produces sudden retrosternal chest pain, and air can track to the neck and chest to create palpable crepitus. Together, chest pain with subcutaneous crepitus is the hallmark finding in this scenario, often with rapid progression to fever or sepsis if not treated promptly. The other descriptions don’t fit the pattern: epigastric pain relieved by meals points to peptic disease; hematemesis without chest symptoms could be a GI bleed without mediastinal air; and lacking respiratory symptoms would be unlikely in the setting of an esophageal rupture with pneumomediastinum.

A tear in the esophagus after vomiting or recent instrumentation allows air to escape into the mediastinum, causing pneumomediastinum. This irritation from the mediastinal air produces sudden retrosternal chest pain, and air can track to the neck and chest to create palpable crepitus. Together, chest pain with subcutaneous crepitus is the hallmark finding in this scenario, often with rapid progression to fever or sepsis if not treated promptly.

The other descriptions don’t fit the pattern: epigastric pain relieved by meals points to peptic disease; hematemesis without chest symptoms could be a GI bleed without mediastinal air; and lacking respiratory symptoms would be unlikely in the setting of an esophageal rupture with pneumomediastinum.