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Boerhaave Syndrome, Emergency Medicine

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Boerhaave Syndrome, Emergency Medicine

Basics

Description

The vague nature of symptoms often lead to a delay in outcome and poorer prognosis

Thoracic or general surgeon must be consulted for admission and possible operative intervention.

530.4 Perforation of esophagus

  • Spontaneous esophageal rupture from sudden combined increase in intra-abdominal pressure and negative intrathoracic pressureCauses complete, full-thickness (transmural), longitudinal tear in esophagus
  • Esophagus has no serosal layer (which normally contains collagen and elastic fibers):Results in weak structure vulnerable to perforation and mediastinal contaminationEsophageal wall is further weakened by conditions that damage mucosa (i.e., esophagitis is of various causes).
  • Majority of perforations occur at left posterolateral wall of the lower third esophagus.
  • Significant morbidity/mortality (most lethal GI tract perforation):Owing to explosive nature of tearOwing to almost immediate contamination of mediastinum with contents of esophagusOverall mortality can approach 20%Mortality can double if treatment is delayed >24 hr from ruptureCervical rupture associated with the lowest mortality, followed by abdominal and thoracic rupture, respectively
  • Causes complete, full-thickness (transmural), longitudinal tear in esophagus
  • Results in weak structure vulnerable to perforation and mediastinal contamination
  • Esophageal wall is further weakened by conditions that damage mucosa (i.e., esophagitis is of various causes).
  • Owing to explosive nature of tear
  • Owing to almost immediate contamination of mediastinum with contents of esophagus
  • Overall mortality can approach 20%
  • Mortality can double if treatment is delayed >24 hr from rupture
  • Cervical rupture associated with the lowest mortality, followed by abdominal and thoracic rupture, respectively

Etiology

  • Associated with:Forceful vomiting and retching (most common)Heavy liftingSeizuresChildbirthBlunt traumaInduced emesisCaustic ingestionsLaughingHistory of Barrett ulcerHistory of HIV/AIDSHistory of pill esophagitis
  • Common in middle-aged men
  • Medical procedures cause over 50% of all perforations.
  • Forceful vomiting and retching (most common)
  • Heavy lifting
  • Seizures
  • Childbirth
  • Blunt trauma
  • Induced emesis
  • Caustic ingestions
  • Laughing
  • History of Barrett ulcer
  • History of HIV/AIDS
  • History of pill esophagitis
  • Described in female neonates but rarely seen
  • Consider caustic ingestions

Diagnosis

Signs and Symptoms

  • Often no classic symptoms
  • Most common symptoms:Chest or epigastric pain after vomiting/retching
  • Mackler triad:Vomiting/retchingChest painSubcutaneous emphysema
  • Retrosternal chest pain present in most patients:Often pleuriticRadiates to back or left shoulderWorsens with swallowing
  • Odynophagia
  • Swallowing may precipitate coughing
  • Frequently, a history of alcoholism or heavy alcohol ingestion may be elicited
  • Chest or epigastric pain after vomiting/retching
  • Vomiting/retching
  • Chest pain
  • Subcutaneous emphysema
  • Often pleuritic
  • Radiates to back or left shoulder
  • Worsens with swallowing
  • Dyspnea
  • Diaphoresis
  • Subcutaneous emphysema in neck and chest wall
  • Mediastinal crackling on auscultation (Hamman crunch)
  • Pleural effusions
  • Tachypnea
  • Fever
  • Shock, in more severe cases
  • If untreated, mediastinitis will develop and abscesses will form.
  • Not usually associated with bleeding

Essential Workup

  • Upright chest radiographs (preferably posteroanterior and lateral views if tolerated) evaluating for:PneumomediastinumSC emphysemaPleural effusion (left side)PneumothoraxWidened mediastinumHydropneumothoraxEmpyemaFree peritoneal airNaclerio "V" sign:V-shaped radiolucency seen through the heart (air in left lower mediastinum)
  • Contrast esophagram identifies leak in esophagus:Aids in decision of which type of surgical approachControversy exists regarding contrast use, water-soluble vs. bariumWater-soluble contrast material was thought to be less toxic if extravasated into the mediastinum; however, if aspirated may cause necrotizing pneumonitis and has a higher rate of false negativesBarium, more sensitive for diagnosing perforation, but more irritating to the mediastinumIf esophagus is intact, use barium contrast for better detail
  • Pneumomediastinum
  • SC emphysema
  • Pleural effusion (left side)
  • Pneumothorax
  • Widened mediastinum
  • Hydropneumothorax
  • Empyema
  • Free peritoneal air
  • Naclerio "V" sign:V-shaped radiolucency seen through the heart (air in left lower mediastinum)
  • V-shaped radiolucency seen through the heart (air in left lower mediastinum)
  • Aids in decision of which type of surgical approach
  • Controversy exists regarding contrast use, water-soluble vs. barium
  • Water-soluble contrast material was thought to be less toxic if extravasated into the mediastinum; however, if aspirated may cause necrotizing pneumonitis and has a higher rate of false negatives
  • Barium, more sensitive for diagnosing perforation, but more irritating to the mediastinum
  • If esophagus is intact, use barium contrast for better detail

Diagnosis Tests & Interpretation

  • CBC
  • PT/PTT/INR
  • Blood cultures
  • Pleural effusion:Amylase contentpH (<6)Undigested food particles
  • ECG
  • Amylase content
  • pH (<6)
  • Undigested food particles
  • CXR
  • Endoscopy:Controversial because this may extend perforation and/or introduce air into mediastinum
  • CT chest:Sensitive for identifying free air, periesophageal fluid, mediastinal widening, air or fluid in pleural spaces; however, does not isolate lesionIndicated if esophagram cannot be obtainedEvaluates other intrathoracic structures
  • Controversial because this may extend perforation and/or introduce air into mediastinum
  • Sensitive for identifying free air, periesophageal fluid, mediastinal widening, air or fluid in pleural spaces; however, does not isolate lesion
  • Indicated if esophagram cannot be obtained
  • Evaluates other intrathoracic structures

Differential Diagnosis

  • Cholecystitis
  • Dissecting aortic aneurysm
  • Intestinal obstruction
  • Lung abscess
  • Mesenteric thrombosis
  • Myocardial infarction
  • Pneumothorax
  • Pericarditis
  • Pneumonia
  • Pancreatitis
  • Pulmonary thromboembolism
  • Ruptured abdominal viscus
  • Spontaneous pneumomediastinum (clinically benign)

Treatment

Pre-Hospital

  • Airway control must be established if patient unresponsive or airway patency in jeopardy.
  • Establish 2 large-bore intravenous catheters and treat hypotension with 0.9% NS.
  • Avoid opiates until patient is in ED to avoid complication of hypotension.

Initial Stabilization/Therapy

  • ABCs
  • Airway control: 100% oxygen or intubate patient if unresponsive or airway patency is in jeopardy.
  • Establish intravenous access and treat hypotension:Administer 1 L (20 mL/kg) bolus with 0.9% NS (or lactated Ringer solution).Initiate dopamine if blood pressure does not respond to fluids.Central catheter placement if condition of patient remains unstable for more efficient delivery of fluids and monitoring of central venous pressure
  • Administer 1 L (20 mL/kg) bolus with 0.9% NS (or lactated Ringer solution).
  • Initiate dopamine if blood pressure does not respond to fluids.
  • Central catheter placement if condition of patient remains unstable for more efficient delivery of fluids and monitoring of central venous pressure

Ed Treatment/Procedures

  • NPO
  • Careful placement of a nasogastric tube to decompress the stomach
  • Bladder catheter to monitor urine output
  • Expedient diagnosis to decrease incidence of morbidity/mortality
  • Prompt surgical consultation
  • Definitive treatment:Surgical repairEndoscopic stent placement, considered in appropriate patientsConservative management, may be considered in patients with a contained perforation
  • Initiate broad-spectrum antibiotics directed against oral microflora and gastrointestinal pathogens:Ampicillin/sulbactam + gentamicinImipenem/Cilastatin
  • Surgical repair
  • Endoscopic stent placement, considered in appropriate patients
  • Conservative management, may be considered in patients with a contained perforation
  • Ampicillin/sulbactam + gentamicin
  • Imipenem/Cilastatin

Medication

  • Ampicillin/sulbactam: 3 g IV q6h
  • Dopamine: 2-20 Ī¼g/kg/min IV per bolus
  • Gentamicin: 2 mg/kg load, then 1.7 mg/kg IV q8h or 5-7 mg/kg IV QD (assuming normal renal function)
  • Imipenem/cilastatin: 250-500 IV q6h

Follow-Up

Disposition

  • Cervical esophageal perforations may be treated by drainage alone.
  • All thoracic and abdominal perforations require surgical intervention.

Followup Recommendations

Pearls and Pitfalls

  • Chest radiographs done immediately after injury may be normal.
  • Left pleural space involvement is usually associated with a distal esophageal perforation.
  • Right pleural space involvement is usually associated with proximal esophageal perforations.
  • If esophagram is negative and there is high suspicion, repeat with patient in left and right decubitus positions.
  • Immediate surgical consultation is the keystone of management.
  • Significant increases in mortality are seen with delay in diagnosis and management.

Additional Reading

  • Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thoracic Surg. 2004;77:1475-1483.
  • Katabathina VS, Restrepo CS, Martinez-Jimenez S, et al. Nonvascular, nontraumatic mediastinal emergencies in adults: A comprehensive review of imaging findings. Radiographics. 2011;31:1150-1153.
  • Onat S, Ulku R, Cigdem KM, et al. Factors affecting the outcome of surgically treated non-iatrogenic traumatic cervical esophageal perforation: 28 years experience at a single center. J Cardiothorac Surg. 2010;5:46.
  • Vogel SB, Rout WR, Martin TD, et al. Esophageal peforation in adults: Aggressive, conservative treatment lowers morbidity and mortality. Ann Surg. 2005;241:1016-1023.
  • Wu JT, Mattox KL, Wall MJ Jr. Esophageal perforations: New perspectives and treatment paradigms. J Trauma. 2007;63:1173-1184.

Codes

ICD9

ICD10

SNOMED

  • 19995004 Spontaneous rupture of esophagus (disorder)