Boerhaave Syndrome

What is Boerhaave Syndrome?

This is a syndrome that is also referred to as “Spontaneous esophageal rupture”. It is a very rare – only accounting for sixteen (16) % of all ruptures that are traumatic to the esophagus. This is a very serious condition. This syndrome is categorized by a total rupture thru the entire wall of the esophagus caused by vomiting that is forceful – causing barogenic trauma.

Vomiting that is uncoordinated with diaphragmatic contraction as well as pyloric closure against a contracted cricopharyngeal muscle causes a rise in intraluminal pressure and is believed to be the underlying cause of this syndrome. The most common rupture site is the left posterolateral wall of the lower third of the esophagus which is believed to be the point of the esophagus that is weakest.

Symptoms

Individuals with the hole in the mid portion or lower portion of the esophagus can have the following symptoms:

  • Swallowing difficulties
  • Difficulty breathing
  • Chest pain

Other signs can include:

  • Fever
  • Fast breathing
  • Blood pressure is low
  • Rapid heart rate

Individuals with the tear in the top portion of the esophagus might have:

  • Stiffness or pain in the neck
  • Bubbles of air beneath the skin

An X-ray of the chest will expose air in the chest’s soft tissues, leaks of fluid from the esophagus into spaces surrounding the lungs, or a lung collapse might be revealed.

A CT scan of the chest might expose in the chest an abscess or cancer of the esophageal. X-rays that are taken after the individual drinks a dye that is non-harmful might help locate the exact site of the tear.

Beside severe chest pain other common symptoms of this syndrome can include:

  • Pain that travels to the back
  • Severe abdominal pain
  • Upper back pain
  • Upper abdominal pain
  • Nausea and vomiting
  • Voice that is hoarse
  • Choking
  • Hiccups

Causes

A hole or tear in the esophagus can let contents of the esophagus pass into the mediastinum which is the surrounding area in the chest. This frequently causes infection of the mediastinum referred to as mediastinitis.

Boerhaave syndrome is most often caused by an injury during a medical procedure. But, since more flexible instruments are used now this occurs rarely.

The esophagus can also become perforated due to:

  • A tumor
  • Gastric reflux accompanied by ulceration
  • Previous esophagus surgery
  • Swallowing foreign objects or chemicals that cause corrosion, such as household cleansers, disk batteries or battery acid
  • Injury or trauma to the esophagus or chest
  • Vomiting that is violent

Some causes that occur less frequently include:

  • Injuries or blunt trauma to the esophagus area
  • Injury to the esophagus during an operation on another organ nearby

Treatment

Management that is ideal involves combining a conservative as well as a surgical approach.

Mainstays of therapy include:

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  • Administering IV broad spectrum antibiotics
  • Administering fluids thru IV
  • Draining any fluid that collects around the lung using a chest tube
  • Surgical intervention that is prompt

If very little or no fluid has leaked, placing a stent in the esophagus may help to avoid surgery.

Often a perforation that is in the upper neck region, part of the esophagus can heal by itself if the individual does not eat or drink for a certain time period. Nutrition can be supplied thru a stomach tube for feeding.

The decision to use medical intervention only or an aggressive approach of medical as well as surgical intervention usually depends on the below factors:

  • Time between individual seeking medical attention and diagnosis
  • Perforation extent
  • Overall condition medically of the individual

Surgery

The majority of physicians believe that surgical intervention is the standard of care particularly in cases where the diagnosis is made within the first 24 hours.

Repair of the rupture that is direct with acceptable drainage of the pleural and mediastinum cavity offers the best rates of survival.

The favored surgical method is a left thoracotomy, although laparotomy might be needed if the rupture or tear spreads into the lower esophagus.

  • Various techniques, such as the use of an omental flap, can be used to support the closure that is primary.
  • Gastrostomy and jejunostomy tubes frequently are placed to help in drainage and for providing nutrition.

The strength of the tissue surrounding the tear is a factor that is important in choosing the surgical method to use.

  • For individuals who have had a diagnosis delay – more than 24 hours, the primary repair might not be possible.
  • After 24 hours, the edges of the wound often are still, edematous and friable.

But many substitutions to primary repair are accessible.

  • The more common substitution consists of creating of an esophageal deviation by use of end-cervical or a loop esophagostomy. This lets the wound heal by secondary means.
  • The use of T-tubes has also been described. T-tubes cause a creation of a well-ordered fistula and a route of drainage for secretion of the esophageal as well as gastric materials that is refluxed.
  • There is one study that noted that the option of using primary repair may still be considered for perforations as old as 72 hours.

There are also newer procedures that involve using plastic-covered metallic stents that are self-expanding.

  • These are acceptable alternatives only when every other involvement choice has been exhausted.
  • The use of stents in this syndrome is advised for cases that have had extreme delays in diagnosis or a failure of conservative management.
  • The continuing effects of placement of these stents in Boerhaave syndrome has not been evaluated adequately.

Complications

Possible complications consist of:

  • Destruction of the esophagus that is lasting
  • Formation of abscess around and in the esophagus
  • Infection around or in the lungs

This condition may progress to shock and even death if not treated.

For individuals with a diagnosis that is early – 24 hours or less, the prognosis is good. Survival rate is approximately 90% when surgery occurs within 24 hours. But, this rate drops to about 50% when treatment is delayed.

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