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Non-ST-elevation acute coronary syndrome — MCCQE Part 1 MCQ

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HardChest PainNon-ST-elevation acute coronary syndromeMCCQE Part 1

After forceful vomiting, a 55-year-old develops abrupt severe retrosternal pain, dyspnea and subcutaneous emphysema. CT with water-soluble contrast shows a distal esophageal leak with a contaminated left pleural collection. What is the best immediate management?

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Correct answer: B — Keep nil by mouth, resuscitate, give IV antibiotics, and obtain urgent source control

This is Boerhaave syndrome with free contamination of the pleural space, a surgical and critical-care emergency. Stop oral intake, resuscitate, give broad-spectrum intravenous antimicrobials covering oral and gastrointestinal flora, and involve thoracic surgery and advanced endoscopy immediately. The leak and infected pleural collection require prompt operative or selected endoscopic closure plus drainage; antibiotics alone do not provide source control. Blind instrumentation can enlarge the perforation. A normal early blood pressure does not predict a benign course, and delayed treatment sharply worsens sepsis and mortality. Anticoagulation is dangerous once a perforation is demonstrated.

Reference: Merck Manual Professional, Esophageal Rupture: https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/esophageal-rupture