• Charlotte Derr and Jessica Maloney Drake.
• University of South Florida, FL, USA.
• Am J Emerg Med. 2012 Nov 1;30(9):2093.e1-3.

AbstractA 69-year-old man presented to the emergency department with hematemesis, hypotension, tachycardia, and hypothermia. The emergency physician performed a bedside ultrasound of the chest, heart, and abdomen. The heart was unable to be visualized in the parasternal, apical, or subxiphoid windows, and free fluid and particulate matter were visualized in the chest and abdomen. The inability to visualize the heart in the normal cardiac windows suggested a diagnosis of pneumopericardium. Based upon the patient's presenting symptoms and ultrasound findings, an esophageal perforation was suspected. Esophageal perforation is a medical emergency. Deterioration and death due to sepsis can occur within hours of presentation [6]. Although there is a great deal of literature discussing the diagnosis of esophageal perforation by chest radiograph, computed tomography (CT), and esophagography, there are no articles on the role of ultrasound. Esophageal perforation may result in the communication of air between the esophagus and pericardium and the leakage of gastric contents into the chest and peritoneal cavity. The presence of air in the pericardial sac results in nonvisualization of the heart on ultrasound. Fluid in the chest and abdomen may be visualized in the posterior upper abdominal windows. Although these ultrasound findings alone are not entirely specific for esophageal perforation, when coupled with a high index of suspicion due to the patient presentation, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques to make the diagnosis of esophageal perforation.

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