Spontaneous esophageal rupture: a frequently missed diagnosis

The objective of this study was to determine the diagnostic features of spontaneous esophageal rupture and compare them with those traditionally applied in making this diagnosis. A retrospective 15-year chart review was performed on all cases listing esophageal rupture as a diagnosis. Only those cases diagnosed by contrast studies or direct visual confirmation were included. Facets of the history, physical examination, laboratory results, and X-ray procedures were examined and compared with the "classic" presentation of this diagnosis as noted in current medical texts. Fourteen cases of confirmed esophageal rupture were found. Only a small minority of cases presented in a fashion resembling a classic case. Esophageal rupture was the admitting diagnosis in 29 per cent of the cases. Laboratory values associated with esophageal rupture included elevated white blood cell count and hypoxia. The chest X-ray was abnormal in all but one patient, with findings of pneumothorax and/or pleural effusion in the majority. We conclude that reliance on classic findings will lead to misdiagnosis in the vast majority of cases presenting to the Emergency Department. Conversely, toxic appearance, pleural effusion, pneumothorax, elevated white blood cell count, azotemia, and hypoxia are all positively associated with this disease. In toxic-appearing patients with pleural effusions and/or pneumothoraces, spontaneous esophageal rupture should be considered.