# A Critical Combination of Esophageal Rupture and Upside-down Stomach: A Case Report

## TL;DR

This case report describes a rare combination of esophageal rupture and upside-down stomach in an elderly patient, emphasizing the importance of prompt diagnosis and treatment.

## Contribution

The paper presents a unique clinical case combining two rare and life-threatening conditions, highlighting diagnostic and management challenges.

## Key findings

- A patient with esophageal perforation and upside-down stomach was successfully treated with surgical repair and intensive care.
- Clinical suspicion based on symptoms like chest pain after vomiting and subcutaneous emphysema is crucial for diagnosing rare conditions.
- Prompt intervention significantly improves outcomes in cases of Boerhaave syndrome and gastric volvulus.

## Abstract

Spontaneous esophageal rupture, or Boerhaave syndrome, and upside-down stomach are rare pathologies associated with grave sequelae. Boerhaave syndrome can have a mortality rate as high as 44%. Upside-down stomach accounts for less than 5% of hiatal hernias and can lead to incarceration and volvulus.

An 80-year-old woman presented to the emergency department with sudden onset, severe epigastric pain. Physical examination revealed normal vital signs with mild epigastric tenderness. Imaging obtained revealed a large hiatal hernia and findings concerning for esophageal perforation. The patient was started on 3.375 grams of intravenous piperacillin/tazobactam, and transfer to a tertiary care facility was initiated. After transfer, esophagography confirmed a perforation near the gastroesophageal junction and findings consistent with an upside-down stomach. The patient underwent successful repair of the esophageal perforation and gastropexy followed by intensive care unit admission and ultimately discharge.

Boerhaave syndrome and upside-down stomach are two conditions with high associated morbidity and mortality requiring prompt intervention. Information obtained in the history and physical examination including acute onset of chest pain after vomiting, tachypnea, subcutaneous emphysema, and hypoxia can assist in the diagnosis of the described pathologies. These signs and symptoms can be subtle on examination but are important in raising clinical suspicion for an otherwise rare etiology for acute onset chest pain.