A 54 year old man presents with severe central chest pain for 2 hours, which was acute in onset and is associated with nausea, vomiting and sweating. His medical and family histories are unremarkable. He is a social drinker only and does not smoke. A recent check up showed a normal fasting blood glucose, lipid profile, renal and liver functions. Serial ECGs show sinus tachycardia only, while troponin-I levels are within normal limits.
S. Amylase : 47 U/l (range: 23 - 85) S. Lipase : 15 U/l (range: 7 - 60)
The echocardiogram shows no structural cardiac defects or wall motion abnormalities. The right ventricle is not dilated and shows normal function. The left ventricular ejection fraction is 65%. The thoracic aorta appears normal.
The chest x-ray shows air in the mediastinum and a small right sided pleural effusion. There is no air under the diaphragm.
The gastrografin swallow test shows extravasation of contrast from the right lower esophagus into the right pleural cavity.