Han Meizi, Xia Xiaojie, Mitsos Sofoklis, Lin Jules, Stuart Christina M, Yu Le
Heilongjiang University of Traditional Chinese Medicine, Harbin, China.
Department of Cardiology, Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, China.
J Thorac Dis. 2024 Nov 30;16(11):8117-8125. doi: 10.21037/jtd-24-1616. Epub 2024 Nov 21.
Esophageal perforation is a rare but life-threatening condition associated with a high mortality rate and often presents with nonspecific clinical manifestations that can lead to delayed diagnosis and treatment. When combined with ST-segment elevation on electrocardiography (ECG), it can be particularly challenging to distinguish esophageal perforation from acute inferior myocardial infarction, as the two conditions may share similar ECG findings.
We report the case of a 65-year-old man with a significant history of long-term alcohol consumption who presented to our hospital (the Affiliated Hospital of Liaoning University of Traditional Chinese Medicine) with persistent oppressive pain in the anterior and posterior left chest. Initially, the patient was diagnosed with acute coronary syndrome based on the ECG findings, which showed Q-wave and ST-segment elevation in the inferior leads. However, further dynamic monitoring of myocardial necrosis markers, including myoglobin and troponin I, yielded negative results inconsistent with acute myocardial infarction. Subsequent enhanced computed tomography revealed thickening and discontinuity of the wall of the thoracic esophagus with an irregular, mixed-density shadowing of the surrounding soft tissue confirming the diagnosis of esophageal rupture. Despite prompt recognition and transfer to a hospital with surgical capabilities, the patient tragically succumbed to esophageal rupture and hemorrhage while awaiting surgery.
This case highlights the importance of maintaining a broad differential, including esophageal rupture, in patients exhibiting necrotic Q waves and ST-segment elevation in the inferior wall of the ECG, especially in the absence of reciprocal changes in the lateral leads and the lack of abnormal markers of myocardial necrosis. Prompt recognition of this rare but potentially fatal condition is crucial for initiating appropriate treatment and improving patient outcomes. Emergency physicians should be aware of this atypical presentation of esophageal perforation mimicking an acute myocardial infarction and consider this differential diagnosis when faced with discordant clinical and diagnostic findings.
食管穿孔是一种罕见但危及生命的疾病，死亡率高，常表现为非特异性临床表现，可导致诊断和治疗延迟。当与心电图（ECG）上的ST段抬高同时出现时，将食管穿孔与急性下壁心肌梗死区分开来可能特别具有挑战性，因为这两种情况可能有相似的心电图表现。
我们报告一例65岁男性患者，有长期大量饮酒史，因左胸前、后持续压榨性疼痛前来我院（辽宁中医药大学附属医院）就诊。最初，根据心电图表现，患者被诊断为急性冠状动脉综合征，下壁导联显示Q波和ST段抬高。然而，对包括肌红蛋白和肌钙蛋白I在内的心肌坏死标志物进行进一步动态监测，结果为阴性，与急性心肌梗死不符。随后的增强计算机断层扫描显示胸段食管壁增厚且连续性中断，周围软组织有不规则的混合密度阴影，确诊为食管破裂。尽管及时识别并转至有手术能力的医院，但患者在等待手术期间不幸死于食管破裂和出血。
本病例强调了在心电图下壁出现坏死Q波和ST段抬高的患者中，保持广泛鉴别诊断的重要性，包括食管破裂，特别是在侧壁导联无对应改变且缺乏心肌坏死异常标志物的情况下。及时识别这种罕见但可能致命的疾病对于启动适当治疗和改善患者预后至关重要。急诊医生应意识到这种模仿急性心肌梗死的食管穿孔非典型表现，并在面对不一致的临床和诊断结果时考虑这种鉴别诊断。
