Beyond the obvious: spontaneous esophageal perforation mimicking flank pain

Abstract

Spontaneous esophageal perforation, also known as Boerhaave syndrome, is a rare but potentially fatal condition that classically presents with chest pain, vomiting, and subcutaneous emphysema. Atypical presentations can lead to diagnostic delays and increased morbidity and mortality rates. A 51-year-old male presented to the emergency department with isolated left flank pain. Initial clinical assessment suggested renal pathology, which prompted physicians to order a non-contrast thoracoabdominopelvic computed tomography (CT) scan. The CT scan unexpectedly revealed bilateral diffuse subcutaneous emphysema and left pleural effusion. Following chest tube insertion, food particles were recovered from the pleural drainage, which established the diagnosis of esophageal perforation. Emergency surgical repair was performed successfully with a good clinical outcome. This case highlights the importance of maintaining high clinical suspicion for esophageal perforation even in patients presenting with atypical symptoms. The absence of classic triad symptoms should not exclude this diagnosis from consideration. CT imaging can provide crucial diagnostic information when the clinical presentation is unclear or atypical.