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An unusual cause of chest pain

BMJ 2009; 339 doi: (Published 12 August 2009) Cite this as: BMJ 2009;339:b3004
  1. Madhuchanda Bhattacharyya, specialist registrar,
  2. Minaxi Dattani, specialist registrar
  1. 1Department of Radiology, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ
  1. Correspondence to: M Bhattacharyya madhuchanda_b{at}

    A 66 year old woman presented to the accident and emergency department with severe chest pain radiating to the back following several episodes of vomiting after a meal.

    On examination, she was unwell with tachycardia and tachypnoea. Her blood pressure was 150/80 mm Hg in the left arm and 138/80 mm Hg in the right arm. Her past medical history included asthma, hypertension, and a previous transient ischaemic attack.

    On admission, she had a mildly raised white blood cell count (14.3×109/l) with neutrophilia (8.58×109/l) and normal haemoglobin (143 g/l). Serum lactate was raised (3.6 mmol/l), but urea and electrolytes were normal. Chest radiography was performed and showed a right sided pleural effusion. Aortic dissection was suspected, and she underwent computed tomography of the chest, abdomen, and pelvis using an aortic protocol. The scan showed a pneumomediastinum with an associated pneumothorax and a right sided pleural effusion. Further radiological investigation was performed (fig 1).


    • 1 What is meant by the term pneumomediastinum?

    • 2 What radiological investigation has been performed and what does it show?

    • 3 What is the diagnosis?

    • 4 How would you manage this patient?


    Short answers

    • 1 Pneumomediastinum is the presence of gas in the mediastinal tissues outside the oesophagus and tracheobronchial tree.

    • 2 This study is a water soluble contrast swallow. It is used in suspected oesophageal rupture to demonstrate a leak from the oesophagus into the mediastinum (fig 2).

    Fig 2 Water soluble contrast …

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