Boerhaave Syndrome

/ Brian Gilberti, PGY-3
Case presented by Dr. Jordan Smedresman
Follow-up Rounds 11/6/2015

CASE
Triage Vitals: T 98.0, HR 92, BP 150/102, RR 20, SpO2 92%
CC: Back pain

HPI
  • 72 yo M with PMH HTN BIBEMS for L sided back pain
  • Started after eating
  • Denied antecedent vomiting
  • Pain associated with dyspnea
PHYSICAL EXAM
Vitals: SpO2 88% on RA, 96% on 2L NC, BP 146/94
General: In acute distress
CV: RRR, no murmurs
Pulm: Diminished breath sounds on L

Abd: Soft, NT

STUDIES
EKG: NSR, no TWIs or ST deviations
POCUS: Possible L-sided pneumothorax
Labs: Unremarkable
CXR: L-sided hydropneumothorax, pneumomediastinum
CT Thorax: Boerhaave syndrome with L-sided pneumothorax, extensive pneumomediastinum

BACKGROUND
  • From sudden increase in esophageal pressure/decrease in intrathoracic pressure
    • Vomiting
    • Childbirth
    • Seizure
    • Prolonged coughing/laughing
    • Weightlifting
  • 15% of esophageal perforations
    • Most iatrogenic > FB or malignancy
  • Most common location of perforation: L posterolateral aspect of distal intrathoracic esophagus
  • Gastric contents in mediastinal cavity → chemical mediastinitis → bacterial infection
  • Pleural cavity may be violated from inflammation or initial perforation
  • ~100% mortality if untreated
CLINICAL MANIFESTATIONS
  • Symptoms (% of pts)
    • Chest pain (89%)
    • Dyspnea (67%)
    • Dysphagia (3%)
    • Neck pain (11%)
    • Neck swelling (6%)
    • Hoarse voice (6%)
  • History of retching (NB: 25-45% don’t have history of vomiting)
  • Crepitus with palpation of chest wall
  • Hamman’s sign: mediastinal crackling with heartbeat
  • Within hours:
    • Odynophagia, dyspnea, mediastinitis, sepsis
DIAGNOSIS
  • CXR
    • Not sensitive; may require hours for signs to develop
    • Findings
      • Mediastinal/free peritoneal air/SQ emphysema
      • Pleural effusion
      • Mediastinal widening

screen-shot-2016-11-29-at-4-51-24-pm

  • CT
    • Findings
      • Esophageal wall edema/thickening
      • Mediastinal widening
      • Air/fluid in pleural spaces/retroperitoneum

screen-shot-2016-11-29-at-4-50-53-pm

MANAGEMENT
  • NPO
  • Broad spectrum abx
  • Protonix gtt
  • CT Surgery consult
    • Surgical candidates:
      • Diffuse extravasation
      • Extension of perforation
      • Sepsis
      • Progression of pneumomediastinum or pneumothorax
      • Patients with empyema

REFERENCES

Blencowe NS, Strong S, Hollowood AD. Spontaneous oesophageal rupture. BMJ 2013;346:f3095.

Carrott PW, Jr., Low DE. Advances in the management of esophageal perforation. Thorac Surg Clin 2011;21:541-55.

Henderson JA, Peloquin AJ. Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader. Am J Med 1989;86:559-67.

Newcomb AE, Clarke CP. Spontaneous pneumomediastinum: a benign curiosity or a significant problem? Chest 2005;128:3298-302.

Triadafilopoulos G. “Boerhaave syndrome: Effort rupture of the esophagus.” Up To Date. http://www.uptodate.com, 26 Apr. 2016. Web. 28 Nov. 2016. https://www.uptodate.com/contents/boerhaave-syndrome-effort-rupture-of-the-esophagus

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