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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1476-1478

Boerhaave syndrome: A dilemma for the private practitioner (a case report)


1 Department of Surgery, Cardiothoracic Surgery Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Surulere, Lagos, Nigeria
2 Department of Anaesthesia, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Surulere, Lagos, Nigeria

Date of Submission16-May-2017
Date of Acceptance14-Oct-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Ezekiel O Ogunleye
Department of Surgery, Cardiothoracic Surgery Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Surulere P.M.B12003, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_365_17

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  Abstract 


Spontaneous esophageal rupture (Boerhaave syndrome) is a rare condition, and many physicians may be unfamiliar with its presentation. A delay in diagnosis and intervention leads to increased morbidity and mortality. We report on a 43-year-old man referred to our facility with a 9-day history of worsening chest pain, respiratory distress, and fever after bouts of retching and vomiting following binge drinking at a party. He presented 8 days earlier at a private hospital, where he underwent a left-sided thoracostomy for empyema thoracis. A computerized tomography of the chest and abdomen was ordered. It indicated a left-sided hydropneumothorax with a collapsed ipsilateral lower lobe, and contrast extravasation into the left pleural space at the distal one-third of the esophagus anterior to the descending thoracic aorta. The diagnosis of Boerhaave syndrome with mediastinitis was confirmed. He was transferred to the ICU and subsequently underwent a left posterior lateral thoracotomy, with esophageal resection performed. Seven days postoperatively, he developed an esophageal leakage, which required an esophageal stent.

Keywords: atypical chest pain, Boerhaave syndrome, esophageal perforation, mediastinitis


How to cite this article:
Ogunleye EO, Adekola OO, Olugbemi AJ, Ojo OO, Sanni SB. Boerhaave syndrome: A dilemma for the private practitioner (a case report). Menoufia Med J 2018;31:1476-8

How to cite this URL:
Ogunleye EO, Adekola OO, Olugbemi AJ, Ojo OO, Sanni SB. Boerhaave syndrome: A dilemma for the private practitioner (a case report). Menoufia Med J [serial online] 2018 [cited 2024 Mar 28];31:1476-8. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1476/252051




  Introduction Top


Boerhaave syndrome is atypical spontaneous esophageal perforation, first described by the Dutch physician Boerhaave[1] in the case of Baron Wassenaer, the Grand Admiral of Holland. The classic presentation in ~50% of cases is that of a middle-aged man with a history of dietary overindulgence and overconsumption of alcohol, who experiences chest pain and subcutaneous emphysema after recent forceful vomiting or retching (Mackler triad)[1]. The lower third of the esophagus and the left lateral position is the most common site in 90% of cases. The mortality rate is 8–60%[2],[3],[4]. It is associated with delayed diagnosis and complications (emphysema, mediastinitis, and septic shock)[5],[6].


  Case Report Top


A.E. was a 43-year-old man who presented with deteriorating chest pain, fever, and respiratory distress of 9 days' duration. He had presented 8 days earlier at a private hospital with a 1-day history of chest pain, difficulty in breathing, forceful retching, and vomiting after a binge of drinking the previous day. A chest radiography performed at the referral hospital indicated left-sided empyema thoracis, for which a thoracostomy tube was inserted.

Examination indicated an acutely ill looking man, pale and febrile (39.7°C), in respiratory distress with flaring alae nasi, and tachypneaic (34 breathes/min), oxygen saturation (SPO2) on room air (76%). An improvised nonfunctional urine bag tubing was fixed to the left seventh intercostal space between the middle and the posterior axillary line. The urine bag contained 350 ml of purulent fluid. On auscultation, percussion notes were stony dull in the mid and lower zones on the left hemithorax. The air entry was reduced in the mid and lower zones on the left side.

There was leukocytosis (35 000 × 106/l) with neutrophilic predominance (85%).

Chest radiography revealed left hydropneumothorax [Figure 1]. Computerized tomography (CT) (eight slice spiral CT scan) of the chest and abdomen showed a left-sided hydropneumothorax with a collapsed ipsilateral lower lobe and contrast extravasation into the left pleural space at the distal one-third of the esophagus anterior to the descending thoracic aorta. An evaluation of sepsis secondary to mediastinitis arising from Boerhaave syndrome was carried out. An emergency left posterior lateral thoracotomy was performed with primary repair of the esophagus rupture.
Figure 1: Left hydropneumothorax.

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Operative findings included a 5 cm linear longitudinal transmural perforation of the posterolateral wall of the distal one-third of the esophagus about 5 cm from the diaphragm anterior to the descending thorax cute. In addition to bilateral pyothorax, extensive slough involving the left lung, pleura, ruptured left mediastinal pleura, and left lower lobe collapse were observed.

He was admitted to the ICU postoperatively for elective mechanical ventilation and critical care. On the third day of admission, enteral feeding was commenced by a nasogastric tube, which was discontinued on the fifth day of admission when the chest tube exudates were identified as identical to enteral feeds. He was immediately commenced on parenteral feeding. A repeat CT on the seventh day indicated esophagus leakage. The patient, however, requested for a referral outside the country for esophageal stent placement.


  Discussion Top


Boerhaave syndrome is an atypical pathology with complete, transmural laceration of the esophagus and a heterogeneous presentation[1],[7]. Our patient was a man and aged 43 years, with rupture in the posterolateral wall of the distal one-third of the esophagus following forceful retching and vomiting after bouts of alcohol. This is the pattern of presentation, with the peak age in the 40s and men constituting 92% of the patients[8]. Similarly, the rupture site is frequently located in the lower esophagus (84%) and left wall (67%), whereas the most frequent inducer was vomiting (64%), followed by other mechanical factors, such as overeating, cough, and trauma (19%)[8].

The chest radiography at the initial presentation showed a left-sided empyema thoracis. Other authors had reported that 90% of chest radiographs were abnormal, with evidence of a left-sided pleural effusion, pneumomediastinum, pneumothorax, hydropneumothorax, subcutaneous emphysema, or the V sign of Naclerio[7]. The latter is caused by radiolucent streaks of gas in the fascial planes behind the heart, which form the letter V and is a specific but insensitive sign of esophageal perforation.

In our patient, a diagnosis was made 9 days after rupture; this is a prolonged and delayed presentation. This is not surprising because Boerhaave syndrome is a rare condition in which the majority of patients are diagnosed after 24 h[6],[7]. However, there was no patient who presented after 9 days as reported by us. One-third of the cases were identified incidentally following a routine CT scan. Hence, it has been suggested that a high index of suspicion is necessary to recognize Boerhaave syndrome[9].

Our patient, although he presented early at the referral center, however, had a 9-day delay before a diagnosis was made by us. The delayed presentation may account for the sepsis and respiratory insufficiency at presentation. Similar observations have been associated with delayed presentation[6],[7].

A primary repair of the esophagus rupture was performed in our patient. There are, however, controversies on primary repair after 24 h of esophageal rupture[7],[10]. Although some scholars advocate primary repair irrespective of the time interval from injury to repair[10], others suggested that primary repair be performed only with diagnosis less than 24 h[7]. They prefer conservative management with small tear and delayed presentation after 5 days, followed by appropriate resuscitation, antibiotics, acid suppression, and enteral nutrition[7]. In our patient, there was esophageal leakage after 7 days of repair; this is not surprising because during the surgery, there was extensive tissue necrosis and slough involving the esophagus, left lung, pleura, and other mediastinal structures, even though the necrotic tissues and sloughs were excised. The risk of leakage may also be related to the time interval between repair and food intake; however, many authors did not state the time taken from injury to oral intake. We concluded that a high index of suspicion is required for an accurate diagnosis of Boerhaave syndrome by the primary physician, and the choice of treatment will depend on the patient's clinical condition and the expertise of the surgeon.

Acknowledgements

1 Ezekiel O Ogunleye: Contributed to the conception and design of the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Adekola O.O.: Contributed to the conception and design of the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Augustine J. Olugbemi: data collection, revising the work critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Olugbenga O. Ojo: revising the work critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Saheed B. Sanni: revising the work critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Boerhaave H. Attrocis nec descripti pruis, morbid histiria. The first translation of the classic case report of the rupture of the esophagus, with annotations. Bull Med Libr Assoc 1955; 43:217–240.  Back to cited text no. 1
    
2.
Keighley MRB, Girdwood RW, Ionescu MI, Wooler GH. Spontaneous rupture of the oesophagus. Br J Surg 1972; 59:649–652.  Back to cited text no. 2
    
3.
Wilde PH, Mullany CJ. Oesophageal perforation: a review of 37 cases. Aust NZ J Surg 1987; 57:743–747.  Back to cited text no. 3
    
4.
Tilanus H, Bossuyt P, Schattenkerk ME, Obertop H. Treatment of oesophageal perforation: a multivariate analysis. Br J Surg 1991; 78:582–585.  Back to cited text no. 4
    
5.
Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004; 77:1475–1483.  Back to cited text no. 5
    
6.
Wise MP Salman JB Maynard ND. Boerhaave Syndrome: a diagnostic conundrum. BMJ Case Rep 2009; 2009: bcr07.2008.0375  Back to cited text no. 6
    
7.
Teh E, Edwards J, Duffy J, Beggs D. Boerhaave's syndrome: a review of management and outcome, Interact Cardiovasc Thorac Surg 2007; 6:640–643.  Back to cited text no. 7
    
8.
Kijima M, Aoki T, Nagao F. Experiences in the diagnosis and treatment of spontaneous rapture of the esophagus. A case of rapture concomitant with a gastric cancer -with a review of preexisting proemetic factors reported in Japan. Tokyo Jikeikai Medical J 1987; 102:1483–1487.  Back to cited text no. 8
    
9.
Lawrence DR, Ohri SK, Moxon RE, Townseed ER, Fountain SW. Primary esophageal repair for Boerhaave syndrome. Ann Thorac Surg 1999; 67:818–820.  Back to cited text no. 9
    
10.
Jougon J, McBride T, Delcambre F, Minniti A, Velly JF. Primary esophageal repair for Boerhaave's syndrome whatever the free interval between perforation and treatment. Eur J Cardio-thoracic Surg 2004; 25:475–479.  Back to cited text no. 10
    


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