Abrupt Severe Chest Pain and Vomiting: Remember to Think of a Ruptured Oesophagus (Boerhaave Syndrome)

Abstract

Boerhaave syndrome or spontaneous rupture of the oesophagus is a severe condition commonly misdiagnosed or unrecognized. Prognosis is poor even if the diagnosis is made promptly. We describe a case of Boerhaave syndrome diagnosed after the development of pneumomediastinum and cardiac arrest. Unfortunately, the patient died 48 hours after admission to the Intensive Care Unit. This entity requires a multidisciplinary management approach which may include conservative, surgical or endoscopic procedures. LEARNING POINTS • Boerhaave syndrome is a diagnostic and therapeutic challenge, and rapid diagnosis and management are crucial. • A thoraco-abdominal CT scan with oesophageal opacification is the gold standard investigation. • A multidisciplinary and individualized approach is needed in the management of this condition.

Transhiatal esophagectomy in Boerhaave syndrome – Case report and literature review

“…It commonly happens on the left posterior aspect of the distal esophagus (in 90% of cases), 2–3 cm above gastroesophageal junction [2] , [3] , [9] .This area has a parietal sheet weakness due angulation with left diaphragmatic crus, wall penetration by vessels and nerves and lack of supporting neighboring structures [7] , [8] , [17] .…”

“…BS pathogenesis happens after a violent vomiting against a superior sphincter that is not totally relaxed, due to discoordinated esophageal motility during vomiting, resulting in increased intraluminal pressure and full-thickness rupture of esophagus wall [2] , [3] , [7] , [17] . There are cases that describe BS after epileptic seizure, asthma attack or the Heimlich maneuver [17] . In other few cases there is no apparent predisposing factor [8] .…”

“…Patient findings are usually non-specific which leads to a delayed diagnosis, thus increasing mortality [8] , [17] . The main clinical feature is chest pain after vomiting [2] , [4] .…”

“…Subcutaneous emphysema is the most pathognomonic sign, but is only found in 60% of patients [7] , [18] . In some cases, the patient could present with sepsis and shock due to mediastinal, pleural or abdominal infection [17] . Hematemesis is rare but could be present [7] , [8] .…”

“…Blood and fluid samples are non-specific, although diagnostic thoracentesis can reveal food, increased amylase and pH below 6 [14] , [15] , [17] .…”