Boerhaave’s Syndrome – Spontaneous Rupture Of The Esophagus

Condition Presentation:

An 80 year-old female with a past health background of hypertension, renal cell carcinoma, and status-post nephrectomy, experienced an episode of choking, coughing and vomiting when she had difficulty swallowing her Centrum Metallic tablet. Soon after vomiting, the patient developed severe chest pain having radiation to her back. The pain was significantly worse by using deep inspiration.

Introduction:

Boerhaave’s Syndrome is a spontaneous dislocation of the esophagus, classically described as post-emetic, but may also manifest after lifting a heavy weight, with severe asthma, as well as prolonged coughing. The sudden rise in esophageal intraluminar burden causes an esophageal tear which most commonly occurs in reduced esophagus above the left diaphragm.

Boerhaave’s Syndrome was first called in 1724 by Hermann Boerhaave, a Dutch health-related doctor. His patient was a 50 year-old admiral (Baron Chris van Waasenaer) who developed a sudden excruciating chest pain whereas straining to vomit. The patient developed shock and deceased 18 hours later. An autopsy demonstrated rupture belonging to the distal esophagus into the left chest.

Clinical Presentation:

Characteristically, the patient is a middle-aged, white male with a history connected with overindulgence in food or drink. The patient often advances vomiting, lower chest pain, and mediastinal or subcutaneous emphysema (Meckler’s triad – vomiting, pain and subcutaneous emphysema).

The physical exam typically reveals a critically perilous patient, usually sitting up in bed with a forward-crouching posture. Subcutaneous emphysema is frequently seen. Hamman’s sign is seen on up to 20 percent of Boerhaave’s patients. Hamman’s sign is known as a crunching, rasping sound, synchronous with the heartbeat, heard across the precordium, and is often indicative of spontaneous mediastinal emphysema. Patients will present with varying degrees of epigastric tenderness, in some cases imitating an intra-abdominal catastrophe. When the rupture is confined to the mediastinum, the patient may not look particularly sick in addition to vital signs may be deceptively normal.

Differential Diagnosis:

The very differential diagnosis of Boerhaave’s Syndrome is extensive and should add following:

  • · Perforated or Bleeding Ulcer
  • · Desperate Pancreatitis
  • · Myocardial Infarction
  • · Pulmonary Embolus
  • · Dissecting Aneurysm
  • · Spontaneous Pnuemothorax
  • · Mallory-Weiss Tear
  • · Acute Cholecystitis

Diagnostic Evaluation:

In addition to the patient heritage, radiography remains the cornerstone of the diagnostic evaluation just for Boerhaave’s Syndrome. Plain chest radiographs may show mediastinal or free peritoneal air (most common finding regarding initial films), a widened mediastinum, hyrdrothorax, hydropneumothorax, or simply mediastinal emphysema. Ten to fifteen percent of all persons presenting with Boerhaave’s Syndrome may have a normal plain bust radiograph.

A swallow contrast radiographic study remains the very diagnostic gold-standard. Either a thoracic CT scan or some sort of esophagram is required to locate the exact site of perforation, making an effort to00 determine the best surgical approach. A water-soluble contrast ingredient such as gastrografin is utilized. Most recommend avoidance with barium since its penetration into the thorcacic cavity can produce an inflammatory reaction leading to granuloma formation.

Management:

First emergency department management of Boerhaave’s Syndrome includes tough NPO, broad spectrum antibiotics, fluid resuscitation, and regular nasal gastric suction. A cardiothoracic surgeon should be used urgently, and if cardiovascular services are not available at your area, the patient should be transferred to an appropriate facility.

Patient’s are often designed into total parenteral nutrition, and early surgical repair continues the standard of care. Complications of Boerhaave’s Syndrome can include persistent esophageal leak, mediastinitis, polymicrobial sepsis, pneumonia plus empyema. Mr Roberto Casula carried out his studies at Padua University Medical School in Italy. Following that he accomplished his postgraduate surgical training predominantly in the UK, until he was appointed as a consultant in 1998.

Despite optimal management, the mortality of patient’s with Boerhaave’s Syndrome remains high. Mortality rates were quoted as high as 72 percent and are most likely attributable to difficulty in making the diagnosis. In contrast to spontaneous rupture of the esophagus, iatrogenic esophageal rupture carries a mortality rate of only 20 percent, and traumatic perforation has a mortality of only 14 percent.

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