Gastroenterology
Volume 139, Issue 4 , Pages e8-e9, October 2010

Persistent Right-Sided Chest Pain

  • Wei-Chang Huang, MD

      Affiliations

    • Division of Chest Medicine, Department of Internal Medicine, Chia-Yi Veterans Hospital, Chia-Yi, Taiwan and Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
    • ,
  • Gwan-Han Shen, PhD

      Affiliations

    • Institute of Respiratory Therapy, China Medical University and Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
    • ,
  • Chih-Wei Tseng, MD

      Affiliations

    • Division of Gastroenterology, Department of Medicine, Buddhist Dalin Tzu Chi General Hospital, Chia-Yi, Taiwan and Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan and National Yang-Ming University School of Medicine, Taipei, Taiwan

published online 01 September 2010.

Article Outline

 

Question: A 64-year-old male presented with a 3-day history of persistent, right-sided chest pain, which was exacerbated by breathing, coughing, sneezing, or even talking. Upon arrival at our emergency room, he denied histories of external trauma, instrumentation of the esophagus, and severe cough in the past month. The patient had no fever. Physical examination and laboratory studies were unremarkable except for leukocytosis (16.53 × 103/μL). Chest radiography revealed multiple opacified lesions in the right lung field (Figure A). Computed tomography (CT) of the chest revealed an encapsulated right-sided pleural effusion with bubble formation (Figure B, black arrow head) and a high-density material (Figure B, black arrow) in the lower third of the esophagus.

What is the most likely diagnosis?

See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Back to Article Outline

Answer to the Clinical Challenges and Images in GI Question: Image 4: Esophageal Microperforation by a Fish Bone Associated With Empyema Thoracis 

This patient presented with right-sided pleuritic chest pain associated with empyema thoracis. Chest CT revealed an encapsulated, right-sided pleural effusion and esophageal perforation by a foreign body (Figure B, black arrow). Upper GI endoscopy revealed an oval fish bone approximately 2 × 3 cm in size that was removed with an endoscopic forceps (Figure C). Two ulcers over the lower third of the esophagus (Figure D) were noted after removing the fish bone. The patient's history was reviewed carefully and revealed an episode of sharp pain after accidentally swallowing a fish bone 10 days before admission. The fish bone retained in the esophagus and induced esophageal microperforation, which further resulted in right-sided empyema thoracis. Diagnostic thoracentesis was performed and the bacterial culture yielded Streptococcus mitis. Tube thoracostomy and antibiotic treatment were prescribed. The patient was discharged after 10 days in hospital.

Common causes of esophageal perforation included medical procedures (50%), trauma (20%), spontaneous (16%), and foreign body ingestion (>7%).1, 2, 3 The successful treatment of esophageal perforation depends on the size of rupture, the length of time between rupture and diagnosis, and the underlying health of the patient. Esophageal perforation accounted for only 5% of cases of empyema thoracis,1, 3 but it should be considered in patient with nontraumatic empyema thoracis of unknown cause. Our own case also illustrated that the conservation therapy with antibiotics and adequate drainage was reasonable for patient with esophageal microperforation.

Back to Article Outline

References 

  1. Jones WG, Ginsberg RJ. Esophageal perforation: a continuing medical challenge. Ann Thorac Surg. 1992;53:534–543
  2. Hoeksema PE, Huizinga E. On foreign bodies and perforations of the esophagus. Ann Otol Rhinol Laryngol. 1971;80:36–41
  3. Solomonov A, Best LA, Goralnik L, et al. Pleural empyema: an unusual presentation of esophageal perforation. Respiration. 1999;66:366–368

 Conflicts of interest The authors disclose no conflicts.

 For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).

PII: S0016-5085(10)00099-5

doi:10.1053/j.gastro.2009.11.061

Gastroenterology
Volume 139, Issue 4 , Pages e8-e9, October 2010

Article Tools