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The tranquility of my standby night was interrupted by the familiar ringing of the pager. The message on the screen asked me to go to the emergency room to evaluate a patient with chest pain. For gastroenterologists, "chest pain" is an uncommon symptom; usually, these problems appear in cardiology. But sometimes people with chest pain can cause discomfort due to gastrointestinal discomfort.

When I arrived in the emergency room, the patient was sitting on the bed, leaning forward and gently shaking back and forth in a state of apparent extreme pain. Despite this, Matt, a 60-year-old salesman, was able to tell me what happened. As part of his work, he occasionally has to take potential customers out to business dinners-eating and drinking in high-end restaurants, with a good meal and a lot of wine. Earlier that evening, after several rounds of appetizers, 12 ounces. Rib-eye steak and all the ingredients, tiramisu as dessert, Matt and his colleagues came to the restaurant bar, where he managed to drink three large beers. Obviously full, but very happy, Matt took a taxi home.

On the way back, it was difficult for Matt to breathe fully considering how much he had eaten. Most importantly, alcohol makes him feel sick, and the bumpy taxi makes him even more sick. When the driver drove him to his door, he almost vomited before running through the front door to the bathroom. In a particularly intense moment, he felt a sharp pain and thought that something had torn his chest. But after a few minutes, this feeling passed, and he could go to bed.

After lying down, Matt soon knew something was wrong. The pain in the chest came back, and it started to become more intense. His heart started beating quickly and uncomfortably, and he was sweating. He also noticed that his neck seemed to be injured. At first, Matt thought he had a heart attack, so he called 911 for an ambulance. After arriving in the emergency room, the nurse who performed the initial assessment noticed that he had a fever of 101 degrees Fahrenheit. His electrocardiogram or electrocardiogram confirmed his rapid heart rate, or tachycardia, but he did not show any signs of a heart attack. At that moment, the emergency doctor called me.

When checking Matt, the first thing I noticed was that his neck looked puffy. When I touched the area, I felt a lot of air under his skin. This discovery, known as subcutaneous emphysema, triggered various alarms in my mind. Subcutaneous emphysema can occur in a variety of situations, including trauma victims with chest injuries or deep-sea divers who surface too quickly. Usually, this indicates a serious injury, and the air is no longer confined to the lungs, but escapes to other areas of the chest and neck. Calmly speaking, I asked the emergency doctor to perform a CT scan of Matt's chest and neck immediately.

The CT scan confirmed that there was air under the skin of Matt's neck. What I feared the most was: Matt tore a hole in his esophagus. Now there is a large amount of air in the space between his lungs, called the mediastinum, which has entered the neck under his skin. The tear appears to be located at the lower left end of the esophagus, just above the diaphragm. The diagnosis is clear-Matt suffers from the so-called Burhaf syndrome.

Many tears and ruptures of the esophagus are the result of trauma or complications of other medical procedures, but Burhav syndrome refers to the so-called "spontaneous" rupture of the esophagus. When people vomit, the pressure in the abdominal cavity and esophagus becomes very high, while the pressure in the chest cavity is very low. When the vomiting is particularly severe, or when the patient is vomiting very severely, the pressure in the esophagus becomes unbearable. At this point, a blowout occurred.

A tear in the esophagus is a life-threatening event. Without treatment, it is almost always fatal. Air, saliva, and stomach contents can now leave the esophagus and enter the chest cavity, none of them belong here. The mediastinum is usually a sterile space, but it is susceptible to infection when the esophagus ruptures. Once the infection begins, patients usually experience septic shock, with serious consequences. According to the results of the CT scan, Matt seemed to have only air in the mediastinum, and he did not appear to be infected. But if we do not act quickly, this situation will soon change.

The esophagus itself is an organ that is difficult to manipulate. Surgical repair of a ruptured esophagus is an important task. It may be necessary to fully open the patient's chest to complete this task. Sometimes, small wounds can be repaired by less invasive surgical methods, but the thoracic surgeon who came to see Matt didn't think that would happen here.

I suggest a different approach: esophageal stents. The stent is a flexible metal mesh cylinder coated with silicon and can be placed without surgery. If we can place a stent in the esophagus through the perforated area, it will seal the rupture and provide a passage for saliva and food from the esophagus to the stomach. The stent itself will not repair the perforation, but it will create an environment conducive to healing, so the hole can close by itself. Surgery can repair the hole faster, but it is more risky and more invasive.

After discussing all his options, Matt agreed to undergo stent implantation. We transferred him to the operating room, where he was sedated, and then I inserted a flexible endoscopic camera into his esophagus. Endoscopy revealed that Matt had a 3 cm wide hole at the end of his esophagus. I used a special X-ray machine called a fluoroscope to guide me and insert the stent into his esophagus. The X-ray contrast agent injected into his esophagus did not show any signs of leakage. After that, we woke up Matt and transferred him to the intensive care unit for close monitoring.

In the next few days and weeks, Matt recovered well. Initially fed by a tube, he was soon able to transition to stuttering again. The stent in his esophagus was uncomfortable at first (it was a large object), but he was used to it. Six weeks later, I performed an endoscopy on Matt again and took out the stent. The original hole is now an irregular scar area, but there is no sign of perforation.

Esophageal stents are not magical-they may not completely seal the hole or slide out of place, and the patient is not always easy to tolerate in terms of comfort. Matt was lucky; the stent implantation worked so well that he avoided the operation. After the stent was taken out, he was about to leave the hospital. I overheard on my mobile phone that he was booking another customer's dinner at the steakhouse. My eyebrows raised with concern. Noting me, he put his hand on the phone. "Don't worry, doctor, I learned my lesson. Only small fish fillets for me!"  

Douglas G. Adler is the co-director of the Denver Advanced Therapeutic Endoscopy Center. The case described in the vital signs is real, but the name and some details have been changed.

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