Acute Onset of Retrosternal and Epigastric Pain FREE

A 15-year-old previously healthy male presents to the emergency department with acute onset of severe pleuritic retrosternal and epigastric pain after swallowing a mouthful of cold soda. He has no previous surgeries or major illnesses, no history of trauma, and no recent emesis. Following the onset of pain he waited several hours and ate 4 chili dogs before presenting to the emergency department. Findings from a general physical examination revealed a healthy, well-appearing young man with mild epigastric tenderness but an otherwise benign abdomen and stable vital signs. A lateral chest radiograph (Figure, A) revealed a small amount of pneumomediastinum, and a soft tissue lateral neck radiograph revealed retropharyngeal and paratracheal air. Radiography was followed by performance of a computed tomography scan in the emergency department (Figure, B).

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Esophageal perforation

C. Surgical consultation for joint consideration of conservative management

The key clinical feature in making this diagnosis is recognition that esophageal perforation can be associated with a swallow of a cold, carbonated beverage. Although esophageal perforation in children is most commonly iatrogenic or traumatic in nature,¹ it can also occur as a result of rapidly increased intraluminal pressure. This can occur with vomiting, an obstructing foreign body, or, as in this case, with a large swallow of a cold, carbonated beverage.

Loh and Cooke² have proposed a physiologic mechanism by which the rapid ingestion of a cold substance leads to contraction of the distal esophagus. Simultaneously, the carbonated nature of the beverage causes expansion, possibly compounded by the rapid heating of the liquid bolus, resulting in a substantial localized increase in intraluminal pressure.

To our knowledge, this is the first reported case occurring in the pediatric population of esophageal perforation resulting from rapid consumption of a cold, carbonated beverage. There have been 3 previous reports of esophageal perforation in adults following consumption of a cold, carbonated beverage.^2- 4 Oriscello and Mahal⁴ described a healthy 67-year-old man who sustained 2 esophageal tears while ingesting cold Alka-Seltzer. Similarly, Loh and Cooke² described a 57-year-old woman who sustained a partial perforation due to a cold, carbonated beverage. That patient was treated conservatively, with nothing permitted by mouth and administration of antibiotics and intravenous omeprazole. Broadbent and Lovegrove³ described a 26-year-old man who sustained an esophageal perforation while consuming a cold, carbonated beverage. He was similarly permitted nothing by mouth, administered antibiotics with close observation, and recovered well.

The majority of data on esophageal perforation comes from the adult population. In this group, significant mortality and a high complication rate when treatment is delayed has historically favored operative management. Today, however, most esophageal perforations are rapidly diagnosed and can be managed conservatively or endoscopically.⁵

A similar change has taken place in the pediatric population, in which the high failure and complication rates of operative intervention, combined with the high propensity of children to spontaneously heal, resulted in a shift toward conservative management.⁶ Furthermore, attempts at conservative management including permitting nothing by mouth, administration of antibiotics, and thoracic and esophageal drainage have shown good outcomes.⁶ Esophageal perforations in children are now commonly managed conservatively, with operative intervention reserved for nonresponsive cases.⁶

All available previously reported cases of esophageal perforation attributed to rapid consumption of cold, carbonated beverages have been successfully treated with conservative management.^2- 3 Given this patient's benign presentation and stable vital signs, consideration of conservative management in conjunction with a surgical service (answer C) is also the preferred course of action in this case. Although a gastrograffin swallow study (answer B) would be appropriate to further delineate the extent and location of esophageal injury, in the emergency department setting it is more appropriate to obtain a surgical consultation and initiate basic management principles, such as permitting nothing by mouth and administering antibiotics, prior to initiating further investigations. An immediate diagnostic esophagoscopy (answer A) is incorrect, because the insufflation of air can cause extension of the perforation and can result in an increase in mediastinal contamination.

A gastrograffin swallow study conducted 2 days after admission revealed a persistent esophageal leak, and the patient remained under close observation, with nothing permitted by mouth. The study was repeated 3 days later and revealed resolution of the leak. His diet was gradually advanced without issue, and he was discharged in stable condition the next day.