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From question on page 1278

The scanogram shows a right tension pneumothorax with a large volume of intrathoracic fluid. On insertion of a chest drain there was release of air under pressure and bloodstained fluid with coffee ground effluent.

A diagnosis of spontaneous oesophageal rupture was made, subsequently confirmed at post mortem.

Diagnosis of oesophageal rupture requires a high index of suspicion. Mackler’s triad of symptoms (vomiting, lower thoracic pain, and subcutaneous emphysema) is the classic presentation.

Management principles are control of the oesophageal leak, eradication of sepsis, re-expansion of the lungs, prevention of gastric reflux, nutritional and pulmonary support, administration of appropriate antibiotics, and postoperative drainage of sepsis.

Spontaneous rupture of the oesophagus is a great diagnostic mimic and tension pneumothorax is an extremely rare presentation of this condition. This patient had symptoms that mimicked a pulmonary embolus. Saturation and arterial blood gas improvements masked the severity of his symptoms. Other mistaken diagnoses include myocardial infarction, pancreatitis, perforated peptic ulcer, dissecting aortic aneurysm, and pericarditis.

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