Presentation of Boerhaave’s syndrome as an upper-esophageal perforation associat

lNTRODUCTlON

Spontaneous esophageal rupture refers to the full-thickness rupture of the esophageal wall caused by indirect trauma, non-foreign bodies, non-esophageal, and/or adjacent organ disease; it is also known as Boerhaave’s syndrome[1]. While the incidence of this disease is low, it is easily misdiagnosed at an early stage and progresses rapidly. After the occurrence of an esophageal rupture, due to negative pressure in the pleural cavity, the stomach contents easily enter the mediastinum and thorax, which often causes serious mediastinum infection and empyema in the early stages. If not treated promptly, severe sepsis rapidly develops into multiple organ failure and even death, which is an emergency during thoracic surgery[2]. Therefore, the associated mortality rate is extremely high. Thus, correctly diagnosing spontaneous esophageal rupture in the early stage is of great importance for the survival of patients with spontaneous esophageal rupture.

Herein, we report a case of spontaneous esophageal rupture misdiagnosed earlier as pleural effusion at an early stage and investigated the causes of its misdiagnosis, along with our experience during diagnosis and treatment. We also highlight the importance of reviewing dynamic chest computed tomography (CT) scans for the diagnosis of spontaneous esophageal rupture.

His vital signs were stable and no other specific symptoms were noted.

CASE PRESENTATlON

Chief complaints

An 84-year-old male was admitted to a local hospital, with complaints of shortness of breath, abdominal distension, and vomiting.

1)建立模拟巷道精度验证绝对坐标系。首先使用手持式激光测距仪反复测量验证系统坐标系原点O，巷道中线在底面的投影作为验证系统绝对坐标系的X轴，其正方向为掘进机试验样机的掘进方向，Y轴方向由精密测角仪测量X轴顺时针偏转90°方向，Z轴为O点竖直向上方向。

对称矩阵在消元计算过程中有的一个很特别、但一直被忽视的特点：即规格化之前，第i行对角元以右元素与第i列对角元以下元素数值相等、位置对称；规格化之后，第i行对角元以右元素与第i列对角元以下元素只相差一个对角元的比例系数，位置仍然对称。因此在因子表的形成过程中，可仅计算对角元素和上三角元素，而下三角元素可按列通过规格化前的上三角元素赋值得到，从而省去大量下三角元素的计算及相应的除法计算，大大加快因子表的形成速度。

History of present illness

The patient was admitted to a local hospital, with complaints of shortness of breath, abdominal distension, and vomiting. He did not vomit again during his stay at the hospital.

ACEI类的药物可降低血管紧张素Ⅱ浓度，因此最初用于治疗高血压，但在临床长期应用过程中发现其对于肾脏具有明显保护作用。在本次治疗研究中，采取ACEI类药物治疗的IgA肾病患者的临床总有效率达到90.5%以上，显著高于非ACEI类药物治疗的对照组（71.5%），提示该种药物治疗可明显保护肾功能，此外观察组患者的血清清蛋白等水平均明显优于对照组，提示该种药物治疗可降低甚至不利因子水平，进一步保护肾脏，研究结果与刘宏伟报道基本一致[2]。总之，对于IgA肾病治疗，采取ACEI类药物临床疗效显著，保护患者肾功能。

After admission, the patient agreed to undergo right closed thoracic drainage and grapefruit-like residue drainage fluid was observed (Figure 1C). During the physical examination, subcutaneous emphysema of the right chest wall with crepitus was detected.

History of past illness

During surgery, a right lateral thoracic incision was made. The patient's right chest wall, muscles, and fascia were severely congested and edematous, along with a ruptured esophagus (Figure 1D).

Personal and family history

Spontaneous esophageal rupture, a rare and life-threatening disease, was first reported by Rokicki M in 1724, and to date, a mere 50 cases have been reported in the literature[3]. Based on an epidemiological survey for this disease in Iceland, it has a low incidence of 31 per million per year[4]. Moreover, several studies confirm that men are more prone to morbidity than women and that the highest risk group included those in the 40-60 years age group[5]. Spontaneous esophageal rupture caused by vomiting followed by a large meal often precipitates secondary bacterial infections, which contribute to 50% of the total mortality[6]. Therefore, early diagnosis and surgical treatment are important in the treatment of this disease.

Physical examination

(3)Glenn Selig was in Kabul on business related to his Florida public relations firm when he became one of at least 22 people killed during a 14-hour attack that began Saturday night and stretched into Sunday,his company reported in a statement.

Laboratory examinations

The initial routine blood examination results showed that both WBC count and CRP levels were slightly elevated (WBC: 12.15 x 10/L, CRP: 13.96 mg/L, Table 1).

During hospitalization, laboratory tests also indicated an increase in inflammatory markers.

Imaging examinations

The chest CT scan showed the presence of a small amount of fluid in the right pleural cavity(Figure 1A). Thus, chest CT scanning was repeated. Right-sided pleural effusion with right lung distension insufficiency and perforation of the upper left esophagus were observed (Figure 1B).

FlNAL DlAGNOSlS

Considering the above signs and symptoms, the patient was diagnosed with spontaneous perforation of the upper left esophagus, and an urgent esophageal hiatus repair was performed.

TREATMENT

The patient had no history of lung diseases.

OUTCOME AND FOLLOW-UP

Unfortunately, due to deterioration of his condition, the patient died from infection and respiratory failure.

Based on the evidence, the patient was diagnosed with pleural effusion and recommended to undergo right closed thoracic drainage; however, the patient's family refused given his advanced age.Therefore, antibiotics were prescribed to prevent infection. However, after treatment, blood inflammatory indicators were significantly elevated and did not improve [white blood cell (WBC) count: 19.40× 10/L; C-reactive protein (CRP): 304.90 mg/L] (Table 1). The patient also suffered from intermittent fevers and over time, complained of chest pain. After eight days, the patient was transferred to our hospital.

DlSCUSSlON

No similar disease was identified in his family.

总而言之，在新高考模式下，需要对传统教学方式进行创新，以便提升教学质量。因此，在高中地理教学中，不仅要积极应用电子设备，注重引入国际性案例，提高学生眼界，而且还要根据具体教学内容，开展相应的实践活动，进而可促使学生更灵活的应用地理知识，对其高考成绩的提高具有重要意义。

The patient has provided informed consent for publication of the case. A copy of the written consent is available for review from the Editor-in-Chief of this journal.

To the best of our knowledge, spontaneous esophageal rupture often occurs in the thoracic esophagus and its incidence in the upper thoracic esophagus is relatively rare. The reasons for this are broadly described as follows: the myometrium of the esophagus is divided into two, the inner ring and the outer longitudinal layer. Approximately 2 mm thick elastic fibers are sandwiched between the two layers.Owing to the lack of coherence in the anatomical structure of the esophagus, a sudden rise in intraesophageal pressure (up to 290 mmHg) can lead to rupture at this altered anatomical structure of the esophagus[11]. While esophageal rupture occurs most commonly in the lower third of the left thoracic segment of the esophagus (80%), it is less frequent in the right esophagus, the upper thoracic, and ventral segments of the esophagus[12]. Among the physical signs, right pleural effusion is also uncommon. In the case of the upper thoracic esophageal perforation, prevertebral or subcutaneous air may be present[13]. Herein, we reported in detail, a case of a spontaneous esophageal rupture in the upper thoracic esophagus, with no obvious signs and symptoms in the early stage. Due to the lack of an early dynamic chest CT review, this disease was misdiagnosed.

Collectively, the reasons for the misdiagnosis were as follows: first, the on-admission chest CT report was only suggestive of a right-sided hydropneumothorax, inconsistent with CT presentation in most reports; additionally, chest pain began later during the course of disease progression, along with a lack of other typical manifestations. Finally, upper thoracic esophageal perforation is a rare site of esophageal rupture and the dynamic chest CT scan was not reviewed during hospitalization, thereby leading to early misdiagnosis and a consequent delay in appropriate treatment.

CONCLUSlON

This case report highlights the importance of a dynamic chest CT review, not only for initial identification of the injured segment but also for prioritizing subsequent treatment strategies. Moreover, we also provide clues for clinicians to recognize and diagnose spontaneous esophageal rupture at a rare site(upper-esophageal segment) by reporting this case of spontaneous esophageal rupture and summarizing the reasons for its misdiagnosis.

FOOTNOTES

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

the Natural Science Foundation of Hubei Province, No. 2019CFB798.

Although many cases of spontaneous esophageal rupture have been reported, the lack of specific symptoms of this condition continues to pose a challenge[7]. Mackler's triad comprising an acute presentation of retching or vomiting, lower chest pain, and surgical emphysema, is a clinical manifestation with relatively high specificity for the diagnosis of spontaneous esophageal rupture.However, its incidence is only about 14%[8,9]. Other signs, which are non-specific, including hemodynamic blood instability or the presence of the Hammer sign-on auscultation, can also help in diagnosing the disease[10]. As secondary infection can irritate adjacent organs, symptoms including abdominal pain, nausea, chest tightness, shortness of breath, and dyspnea can also occur. In addition,elevated cardiac biomarkers and amylase also make it difficult to differentiate it from pericarditis,myocardial infarction, peptic ulcer, and other conditions. For patients with clinical suspicion of the disease, early chest CT examination is particularly important as it shows the manifestation of mediastinal or free peritoneal air as the first sign.

The authors have no conflicts of interest in relation to this work.

3.深推“两学一做”，贯彻学习精神。公司领导班子以身作则、率先垂范，每月积极参加党委中心组集中学习，各党支部、党小组通过讲党课、学习研讨、知识竞赛、党员轮训、撰写学习心得等多种方式深入学习宣传贯彻党的十九大精神和***总书记系列重要讲话精神及治国理政新理念新思想新战略，不断武装头脑、指导实践，以高度的责任担当精神，用实际行动和强力举措推动党的十九大精神落地生根、开花结果。

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

1.2 实验设备 DWC150型动物实验加压舱，购于上海 701 所杨园医用氧舱厂。MyLab 30CV型彩色超声成像系统（LA435 超声探头），购于意大利百胜集团公司。BC-2800 Vet型全自动动物血液细胞分析仪，购于深圳迈瑞生物医疗电子股份有限公司。XL1000e 系列全自动凝血测试仪，购于北京众驰伟业科技发展有限公司。

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溥仪冲龄登基，即使做了三载帝王，此时的他也不过是个五六岁的幼童。李凡的目光穿过人群，看着御座上的溥仪，只见他稚嫩而懵懂的眼神扫过身边的太后、下面的臣子，对他们的悲伤忧愁难有感触。

China

Ni Tan 0000-0002-7591-0143; Yin-Hua Luo 0000-0003-4381-7048; Guang-Cai Li 0000-0002-9728-0197;Yilin Chen 0000-0003-1969-9854; Wei Tan 0000-0001-7625-5518; Yue-Hua Xiang 0000-0002-9526-5778; Liang Ge 0000-0003-2147-7652; Di Yao 0000-0002-6966-0416; Ming-Hua Zhang 0000-0003-4577-626X.

Ma YJ

Webster JR

Ma YJ