Mackler's Triad

Q: 54 years male with a previous history of alcohol abuse and a perforated duodenal ulcer is admitted via ED with a diagnosis of Mackler's triad. What is Mackler's triad?

Answer: Mackler's triad includes

• lower chest pain
• vomiting
• subcutaneous emphysema

It is a classic presentation of esophageal rupture (Boerhaave's syndrome), but presents only in a few patients (14%).

 

Notably, the triad has also been reported in the absence of esophageal perforation.

 

Tachypnea and abdominal rigidity are typically accompanied by tachycardia, diaphoresis, fever, and hypotension. Unusual clues include hoarseness caused by involvement of the recurrent laryngeal nerve, tracheal shift, distension of the cervical veins, and proptosis.

 

The condition can quickly progress to multi-organ failure.

#GI

References:

1. Loftus IA, Umana EE, Scholtz IP, McElwee D. Mackler's Triad: An Evolving Case of Boerhaave Syndrome in the Emergency Department. Cureus. 2023 Apr 22;15(4):e37978. doi: 10.7759/cureus.37978. PMID: 37223188; PMCID: PMC10202041.

2. Gunawardene A. Mackler's triad in spontaneous pneumomediastinum. ANZ J Surg. 2023 Jan;93(1-2):437. doi: 10.1111/ans.18147. Epub 2023 Jan 20. PMID: 36660864.

3. Rassameehiran S, Klomjit S, Nugent K. Right-sided hydropneumothorax as a presenting symptom of Boerhaave's syndrome (spontaneous esophageal rupture). Proc (Bayl Univ Med Cent). 2015 Jul;28(3):344-6. doi: 10.1080/08998280.2015.11929269. PMID: 26130884; PMCID: PMC4462217.