Amylase in an Unusual Place – A Roundabout Diagnosis of Esophageal Rupture

Abstract

When presented a patient with a new pleural effusion, Light’s Criteria are applied to determine whether the fluid is transudative or exudative following a thoracentesis. This leads to the underlying etiology of the effusion in 75% of cases. However, occasionally Lights Criteria present a mixed picture, thereby requiring us to expand testing and broaden our differential diagnosis of the effusion as is needed in the case below.

Case: A 66-year-old male presented with a complaint of chest pain, cough, and malaise.  He experienced violent post-operative vomiting and back pain. He was diagnosed weeks later with a loculated pleural effusion found to be an empyema requiring drainage. The exudate drained required more advanced testing, thus leading to our finding of an extremely high amylase level in the exudate. The case report reviews the details and timeline of how an empyema was diagnosed in this patient, and how it was found to be secondary to a post-emetic esophageal perforation.

Discussion/Conclusion: Post-emetic spontaneous esophageal rupture is a serious diagnosis. Oral flora and digestive enzyme migration into a sterile space (para-mediastinum and pleural space) can give rise to major complications. Rapid diagnosis and surgical repair should be made high priority. Esophageal perforations carry a high complication rate and mortality, therefore a patient presenting with chest pain following bouts of vomiting and new cough +/- an abnormal chest x-ray should prompt consideration for esophageal perforation.