PANCE Board Practice Exam

This presentation points to esophageal rupture (Boerhaave syndrome) with resulting mediastinal air, which can cause a crunching sound over the chest (Hamman sign). It’s a medical emergency, so rapid and accurate confirmation is essential. A contrast esophagram using water-soluble contrast (Gastrografin) is the test of choice to establish an esophageal leak. It directly demonstrates extravasation from the esophagus and is preferred initially because it carries less risk of mediastinal irritation if a leak is present. Other tests like chest X-ray can suggest mediastinal involvement but won’t confirm the leak, and endoscopy is avoided early due to potential worsening of the perforation. If the water-soluble study is inconclusive but suspicion remains high, a follow-up study with a different contrast or CT with oral contrast may be performed.