Boerhaave syndrome - case report

Abstract

CONTEXT: Boerhaave syndrome consists of spontaneous longitudinal transmural rupture of the esophagus, usually in its distal part. It generally develops during or after persistent vomiting as a consequence of a sudden increase in intraluminal pressure in the esophagus. It is extremely rare in clinical practice. In 50% of the cases, it is manifested by Mackler's triad: vomiting, lower thoracic pain and subcutaneous emphysema. Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Compared with ruptures of other parts of the digestive tract, spontaneous rupture is characterized by a higher mortality rate. CASE REPORT: This paper presents a 64-year-old female patient whose vomit was black four days before examination and became bloody on the day of the examination. Her symptoms included epigastric pain and suffocation. Physical examination showed hypotension, tachycardia, dyspnea and a swollen and painful abdomen. Auscultation showed lateral crackling sounds on inspiration. Ultrasound examination showed a distended stomach filled with fluid. Over 1000 ml of fresh blood was extracted by means of nasogastric suction. Esophagogastroduodenoscopy was discontinued immediately upon entering the proximal esophagus, where a large amount of fresh blood was observed. The patient was sent for emergency abdominal surgery, during which she died. An autopsy established a diagnosis of Boerhaave syndrome and ulceration in the duodenal bulb. CONCLUSION: Boerhaave syndrome should be considered in all cases with a combination of gastrointestinal symptoms (especially epigastric pain and vomiting) and pulmonary signs and symptoms (especially suffocation). RESUMO CONTEXTO:A síndrome de Boerhaave é uma ruptura longitudinal transmural espontânea do esôfago, normalmente da parte distal. Ela geralmente se desenvolve durante ou após vômitos persistentes como consequência do aumento repentino da pressão intraluminal no esôfago. É extremamente rara na prática clínica. Em 50% dos casos, manifesta-se pela tríade de Mackler: vômitos, dor torácica inferior, enfisema subcutâneo. Hematêmese é uma apresentação incomum porém desafiadora da síndrome de Boerhaave. Em comparação com rupturas de outras partes do tubo digestivo, a ruptura espontânea é caracterizada pela taxa de mortalidade mais elevada. RELATO DO CASO: O artigo apresenta uma paciente do sexo feminino de 64 anos de idade, cujo vômito era preto, quatro dias antes do exame, e continha sangue no dia do exame. Os sintomas incluíam dor epigástrica e sufocação. No exame físico, foi verificada hipotensão, taquicardia, dispneia e abdômen inchado e doloroso. Ausculta revelou estertores laterais na inspiração. A ultrassonografia mostrou estômago dilatado, preenchido com conteúdo líquido. Sucção nasogástrica evacuou mais de 1.000 ml de sangue fresco. Esofagogastroduodenoscopia foi abortada imediatamente ao se entrar no esôfago proximal, onde foi observada grande quantidade de sangue fresco. A paciente foi encaminhada com urgência para cirurgia abdominal, durante a qual ...

Boerhaave’s syndrome: A case report of damage control approach

“…Boerhaave’s syndrome is a rare clinical entity with a mortality rate of 20–50% [5,6]. Its pathophysiology involves a sudden rise in intraluminal oesophageal pressure, most often during or after intense vomiting [1,2]. It accounts for only 15–30% of all oesophageal perforations.…”

“…The others result from iatrogenic, traumatic, foreign-body and disease-related perforations [1,7]. In the majority of cases, the rupture is located in the lower third of the oesophagus, about 2–4 cm above the cardia, where there is a relative scarcity of longitudinal muscle fibers, an absence of local anatomical structural protection, and a large number of associated vascular and neural structures that weaken the oesophageal wall [2,6]. Perforations are usually longitudinal (mean of 22 mm) and the left side is more commonly affected than the right, due to an anatomical weakness of the left posterolateral aspect of the oesophagus just above the diaphragm [6].…”

“…Diagnosis of Boerhaave’s syndrome is challenging as history and symptoms can be nonspecific [2,7,8]. It is reported that there is a male predominance of 2:1–5:1 and is more frequently seen in people aged 50–70 years [9].…”

“…Nevertheless, the principles are the same: sepsis control by limiting diffusion of contamination, adequate drainage, perforation repair and antibiotic treatment [6], because, as we know, the predominant causes of death are sepsis and multiple organ failure [9]. Most authors declare that the surgical approach remains the cornerstone of treatment for most cases of Boerhaave’s syndrome [1,2,4,6,8,11,12]. Finally, “what kind of surgical approach is the best” is another point of controversy: surgical treatment ranges from a less invasive approach consisting of debridement and drainage of the chest cavity to extensive resection of the thoracic oesophagus [1].…”

“…It requires urgent diagnosis and treatment. Diagnosis is challenging, as the classic triad of Mackler (vomiting, lower thoracic pain and subcutaneous emphysema) is present in less than 50% of cases [2]. It requires a multidisciplinary management and, if delayed, severe complications may develop.…”