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Eur J Cardiothorac Surg 2005;28:502-503
© 2005 Elsevier Science NL

Case report

Tension pneumomediastinum after severe vomiting in a 21-year-old female

Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria

Received 14 April 2005; received in revised form 29 April 2005; accepted 2 May 2005.

^* Corresponding author. Tel.: +43 316 385 3302; fax: +43 316 385 4679. (Email: sabine.gabor{at}meduni-graz.at).

	Abstract

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
A 21-year-old female with chronic membranoproliferative nephritis was admitted for suspected esophageal disruption and asthma after severe, prolonged vomiting. At the time of admission she presented with dyspnea, tachypnea, arterial hypotension and tachycardia. Physical examination showed discrete signs of ectopic air at the neck and distended cervical veins. CT-scan of the chest showed severe mediastinal emphysema with compression of the right atrium. After cervical mediastinotomy the cardiorespiratory parameters normalized immediately. Esophagoscopy showed multiple longitudinal mucosal tears between 25 and 45cm; fluoroscopically, there was no leakage of contrast medium. Following conservative treatment the patient recovered completely and was discharged on day 8.

Key Words: Tension pneumomediastinum • Esophagus • Mucosal tear

	1. Introduction

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Tension pneumomediastinum is most commonly associated to traumatic rupture of the tracheobronchial tree [1,2]. Due to impairment of the venous return to the heart it causes arterial hypotension, tachycardia and dyspnea. Typically, the cervical veins are distended. In most cases, there is clinical evidence of severe subcutaneous emphysema at the neck and in the supraclavicular region.

Whereas pneumomediastinum is a typical finding in complete esophageal rupture, it is infrequently present in mucosal tears, where it may be very discrete or even absent [3,4].

We present an unusual case of tension pneumomediastinum following mucosal rupture after severe, prolonged vomiting in a young woman.

	2. Case report

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
A 21-year-old female had a history of membranoproliferative nephritis since the age of 8 years resulting in compensated renal insufficiency and renal hypertension (Urea: 54mg/dl, Creatinine: 2.3mg/dl, Uric acid: 8.3mg/dl).

During the past few months she had experienced repeat episodes of sudden nausea and vomiting. Pregnancy tests had always been negative. At the end of another severe and prolonged attack the vomit had shown blood stains. Because of dyspnea that had developed after the vomiting, the tentative diagnosis of asthma and incipient pneumonia was made by the general practitioner 12h later. She was admitted to a hospital. Chest roentgenogram showed mediastinal emphysema.

Following another fit of vomiting the cardiorespiratory condition of the patient deteriorated rapidly. Esophageal perforation and asthma were suspected.

At the time of admission to the Department of Thoracic Surgery she was dyspnoeic and tachypnoeic (32breaths/min). The heart rate was 160/min, arterial blood pressure was 90/40. Physical examination showed distended veins at the neck, and discrete signs of ectopic air in the depth of the neck on palpation, otherwise the findings were normal. The patient had no fever, and felt no pain. WBC was 18.3G/l, CRP was 11.1mg/l.

CT-scan of the chest showed severe mediastinal emphysema with compression of the right atrium and discrete ground-glass opacities in the right lung.

Under a slight analgo-sedation and local anesthetic, a cervical anterior mediastinotomy was done. After the release of air from the mediastinum heart-rate, blood pressure and respiratory rate normalized immediately. The patient felt no longer dyspnoeic.

Endoscopy revealed multiple longitudinal mucosal tears from 25cm down to the ora serrata. Intra-interventional fluoroscopy showed no leakage of water-soluble contrast medium.

On the first postoperative day a control CT-scan revealed the right lung showing the opacity resolving. The pneumomediastinum had all but disappeared.

Treatment was done by gastric tube for 4 days, parenteral feeding and antibiotics, as well as optimization of the renal parameters and antiemetic medication. Laboratory parameters were controlled every day. After an uneventful recovery, the patient was discharged on day 8 after having showed satisfactory healing of the mucosal tears during control endoscopy. At the time of writing, 2 months after the event, she is well and has no gastrointestinal symptoms whatsoever.

	3. Discussion

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Tension pneumomediastinum requiring surgical intervention is relatively rare. On most occasions it is caused by traumatic rupture of the large airways or by invasive artificial ventilation techniques using volume controlled patterns [5,6].

In spontaneous esophageal ruptures following forceful vomiting intragastric air is thrust into the mediastinum. Depending on the amount of air and on the force of antiperistalsis a considerable pressure may be exerted. Though complete spontaneous rupture of the esophageal wall is inevitably connected with ectopic mediastinal air, tension pneumomediastinum seems to be uncommon in this situation [7]. Up to this time, there are no reports in the literature. In incomplete rupture of the esophagus such as in Mallory–Weiss Syndrome, extramural air may be observed, though much less frequent and in smaller amounts than in ruptures comprising all layers of the esophageal wall [8,9].

In our patient, uncontrollable nausea and vomiting were caused by renal insufficiency [3]. She reported that the fits of vomiting usually lasted about 10min and that there was always ‘much air coming up’.

The special clinical features were the lack of chest pain, and the predominance of respiratory symptoms in absence of obvious soft-tissue emphysema at the neck or in the supraclavicular region. This is why the cause for the dyspnea remained hidden.

The reason why tension pneumomediastinum built up in the present case may be sought in the fact that the multiple shallow mucosal tears probably created a sort of ‘valve-mechanism’ permitting air only to enter the mediastinum but not to escape from it. Cervical mediastinotomy created an immediate and dramatic relief.

Considering the lack of a leakage of contrast medium into the mediastinum, the absence of a pleural effusion and of marked signs of severe inflammation in the laboratory parameters as well as the lack of clinical features of sepsis [10], it was decided to treat the esophageal pathology conservatively while closely monitoring the patient for parameters that might have indicated the onset of mediastinitis (Fig. 1 ).

View larger version (124K): [in this window] [in a new window]   Fig. 1. Tension pneumomediastinum due to spontaneous incomplete rupture of the esophagus. The right atrium is compressed by the ectopic air. Air also circumferentially around the esophagus. Rectangular ground-glass opacity in the right lung.

	References

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 

1. Beg MH, Reyazuddin A, Ansari MM. Traumatic tension pneumomediastinum mimicking cardiac tamponade. Thorax 1988;43:576-577.[Abstract/Free Full Text]
2. Van Stiegmann G, Brantigan CO, Hopeman AR. Tension pneumomediastinum. Arch Surg 1977;112:1212-1215.[Abstract]
3. Level C, de Precigout V, Lasseur C, Hachem D, Berg F, Larroumet N, Carles J, Blanchetier V, Videau J, Combe C, Aparicio M. Spontaneous rupture of the esophagus (Boerhaave-syndrome) in a patient with scleroderma treated by continous ambulatory peritoneal dialysis. Rev Med Int 1997;18:566-570.
4. Liang SG, Ooka F, Santo A, Kaibara M. Pneumomdiastinum following esophageal rupture associated with hyperemesis gravidarum. J Obstet Gynaecol Res 2002;28(3):172-175.[Medline]
5. Weissberg D, Weissberg DO. Spontaneous mediastinal emphysema. Eur J Cardiothorac Surg 2004;26:885-888.[Abstract/Free Full Text]
6. Raith W, Zartner P, Beitzke A. Spontaneous pneumomediastinum as a cause of chest pain. Z Kardiol 2003;92:601-605.[Medline]
7. Uppal S, De PR. Oral presentation of an oesophageal mucosal tear. Postgrad Med J 1999;75(888):615-616.[Abstract/Free Full Text]
8. Rosch W, Eifler R. Incomplete spontaneous esophageal rupture—a variant of the Mallory–Weiss and Boerhaave syndrome. Z Gastroenterol 1983;21(5):205-211.[Medline]
9. Ghanem N, Altehoefer C, Springer O, Furwängler A, Kotter E, Schäfer O, Langer M. Radiological findings in Boerhaave's syndrome. Emerg Radiol 2003;10(1):8-13.[Medline]
10. Port LJ, Kent MS, Korst RJ, Bacchetta M, Altorki NK. Thoracic esophageal perforations: a decade of experience. Ann Thorac Surg 2003;75:1071-1074.[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sabine Elisabeth Gabor Heiko Renner Alfred Maier Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Gabor, S. E. Articles by Smolle Jüttner, F. M. Search for Related Content PubMed PubMed Citation Articles by Gabor, S. E. Articles by Smolle Jüttner, F. M. Related Collections Mediastinum Esophagus - other