Esophageal Rupture Presenting with ST Segment Elevation and Junctional Rhythm Mimicking Acute Myocardial Infarction

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Abstract

Esophageal rupture is a rare but potentially fatal cause of chest pain. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory distress. Over the next 48 hours, the patient developed dynamic ST segment changes on surface electrocardiogram mimicking an inferolateral ST segment elevation MI accompanied by a junctional rhythm. Curiously, his cardiac enzymes remained negative during this time, but his clinical status continued to deteriorate. A subsequent CT scan demonstrated a lower esophageal rupture, and the patient underwent successful endoscopic stenting. While rare, prompt recognition of esophageal rupture is imperative to improving morbidity and mortality. While esophageal rupture has been noted to cause ST segment elevation before, this appears to be the first case associated with a junctional rhythm.

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Most cited references 12

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Evolving options in the management of esophageal perforation.

Diana M Marshall, Lawrence Lee, Sunil Singhal … (2004)

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.

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Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators.

Bradley Wagner, K Gates, E B Sgarbossa … (1996)

The presence of left bundle-branch block on the electrocardiogram may conceal the changes of acute myocardial infarction, which can delay both its recognition and treatment. We tested electrocardiographic criteria for the diagnosis of acute infarction in the presence of left bundle-branch block. The base-line electrocardiograms of patients enrolled in the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial who had left bundle-branch block and acute myocardial infarction confirmed by enzyme studies were blindly compared with the electrocardiograms of control patients who had chronic coronary artery disease and left bundle-branch block. The electrocardiographic criteria for the diagnosis of infarction were then tested in an independent sample of patients presenting with acute chest pain and left bundle-branch block. Of 26,003 North American patients, 131 (0.5 percent) with acute myocardial infarction had left bundle-branch block. The three electrocardiographic criteria with independent value in the diagnosis of acute infarction in these patients were an ST-segment elevation of 1 mm or more that was concordant with (in the same direction as) the QRS complex; ST-segment depression of 1 mm or more in lead V1, V2, or V3; and ST-segment elevation of 5 mm or more that was disconcordant with (in the opposite direction from) the QRS complex. We used these three criteria in a multivariate model to develop a scoring system (0 to 10), which allowed a highly specific diagnosis of acute myocardial infarction to be made. We developed and validated a clinical prediction rule based on a set of electrocardiographic criteria for the diagnosis of acute myocardial infarction in patients with chest pain and left bundle-branch block. The use of these criteria, which are based on simple ST-segment changes, may help identify patients with acute myocardial infarction, who can then receive appropriate treatment.

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Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome.

H Vidarsdottir, S Blondal, T Gudbjartsson … (2010)

Oesophageal perforation is a rare but life-threatening condition with a significant morbidity and mortality. In this retrospective, nationwide study, the results of oesophageal perforation are reported for a well defined cohort, with special emphasis on the incidence, aetiology and results of surgical treatment. 29 consecutive patients (16 males) were diagnosed with perforation of the oesophagus at Landspitali University Hospital between 1980 and 2007. Patients had a mean age of 61 years (range: 7 months-90 years). Type of surgery, complications and survival were recorded. Average follow-up was 76 months. Age-standardised incidence of oesophageal perforation was 3.1/1,000,000 per year during the study period. Out of 29 patients diagnosed with oesophageal perforation, the diagnosis was missed in 5 cases (17%) and first made at autopsy. Iatrogenic injury was the most frequent cause (52%), followed by spontaneous perforation (24%) and foreign body ingestion (17%). Thoracic perforations were seen in 73% of patients, and 14 patients had an underlying oesophageal disease. Nineteen patients were treated surgically, in 16 cases with drainage of the mediastinum via thoracotomy and insertion of chest tubes. The median time from perforation to surgery was 6.5 h and median length of hospital stay was 15 days (range: 9-83). All surgically treated patients survived surgery, and the 5-year overall survival rate was 69%. More than half of all oesophageal injuries in Iceland are caused by a iatrogenic injury. Mortality is significant and is related to a missed diagnosis. Patients treated surgically all survived surgery; however, complications were frequent and their hospital stay was long. © Georg Thieme Verlag KG Stuttgart · New York.