Gastrointestinal: Boerhaave's syndrome
Journal
Journal of Gastroenterology and Hepatology (Australia)
Journal Volume
20
Journal Issue
11
Pages
1788
Date Issued
2005
Author(s)
Abstract
A 54-year-old man was admitted to hospital with severe central chest pain. This was preceded by recurrent vomiting after a high intake of alcohol. On examination, he was febrile and had typical signs of subcutaneous emphysema in his neck and face. Blood tests revealed a mild elevation of aspartate aminotransferase and creatinine kinase but the patient had a normal electrocardiogram. A chest radiograph showed a pneumomediastinum with air in the retrocardiac space and streaks of radiolucencies in the paratracheal spaces as well as in the neck (Fig. 1). Additional findings included soft radiodensities in the left thorax and a small left pleural effusion. A computed tomography scan of the chest (Fig. 2) confirmed the presence of gas surrounding the esophagus (arrow). At emergency surgery, the patient had severe necrosis of the thoracic esophagus and was treated with a surgical diversion procedure. Boerhaave's syndrome is a term that is used to describe spontaneous rupture of the thoracic esophagus induced by forceful retching or vomiting. The syndrome takes the name of Hermann Boerhaave, a Dutch surgeon, who first described the condition in 1724. Characteristic features include chest pain, fever and air in the mediastinum or air in subcutaneous tissues, particularly in the neck. In patients with minor perforations, typical features can be slow to evolve and the differential diagnosis may include myocardial infarction, pancreatitis, pneumothorax and pericarditis. If a minor perforation is suspected, an esophagram should be performed using a water-soluble contrast material. In general, it is preferable to avoid flexible or rigid esophagoscopy as the procedures may enlarge the perforation. Patients with perforation of the thoracic esophagus need to be carefully managed by both physicians and surgeons. If a minor perforation is identified early, non-operative management using intravenous antibiotics can result in a successful outcome. However, most patients with Boerhaave's syndrome require surgery that usually includes debridement of the perforation, primary repair in two layers and drainage of the pleural cavity.
SDGs
Other Subjects
antibiotic agent; adult; article; blood examination; Boerhaave syndrome; case report; computer assisted tomography; conservative treatment; differential diagnosis; esophagus rupture; human; male; priority journal; symptomatology; thorax radiography; vomiting; esophagus; hospitalization; injury; middle aged; pathophysiology; pneumomediastinum; radiography; rupture; subcutaneous emphysema; syndrome; thorax; thorax pain; vomiting; Chest Pain; Esophagus; Humans; Male; Mediastinal Emphysema; Middle Aged; Radiography, Thoracic; Rupture; Severity of Illness Index; Subcutaneous Emphysema; Syndrome; Thorax; Tomography, X-Ray Computed; Vomiting
Publisher
Blackwell Publishing
Type
journal article