Rupture of the abdominal oesophagus: a review

Above and Below the Diaphragm: A Previously Undescribed Case of Recurrent Boerhaave Syndrome Diagnosed With Computerized Tomography Esophagram

Boerhaave syndrome, defined as a spontaneous rupture of the esophagus, is an uncommon clinical entity. Recurrent spontaneous rupture of the esophagus is even rarer and has only been described in a handful of case reports. The rupture most often occurs in the thoracic esophagus. Spontaneous rupture of the intraabdominal esophagus is extremely rare.

The extravasation of gastric contents, including bile, acid, and bacteria, into a body cavity precipitates severe sepsis. This results in a high mortality rate without emergent treatment. Such treatment often necessitates surgical repair with primary closure, tissue grafts, or esophagectomy in particularly severe cases.

This is a case of a 64-year-old male who suffered Boerhaave syndrome twice separated by two years. The patient was transferred from an outside facility initially presenting with chest and abdominal pain, which developed after eating. CT esophagram with water soluble contrast demonstrated contrast extravasation into the right mediastinum/hemithorax, consistent with a diagnosis of Boerhaave syndrome. Repair was accomplished with an intercostal muscle pedicle patch, and the patient was subsequently discharged. This case report details, to our knowledge, the first case of a left intraabdominal and right thoracic esophageal rupture combination.

Anesthesia for Esophageal Surgery

Esophageal surgery comprises a variety of procedures of differing complexity to treat functional and structural disorders of the esophagus. Local disease extension, surgical repair technique, and physical status of the patient primarily dictate anesthetic management of patients with esophageal pathology. Because the esophagus is in close proximity to vital organs and structures, a specific knowledge of the anatomy is essential to realize how esophageal pathology can compromise elemental physiological functions. A com prehensive anesthetic plan requires a detailed under standing of the surgical procedure in terms of approach, the extent of the operation, and associated complica tions. Consideration of comorbid conditions is equally important, as esophageal surgery is frequently per formed in debilitated and polytraumatized patients. The following article will review clinical manifestation, surgi cal therapy, and perioperative anesthetic management of the most commonly encountered esophageal disor ders. Specifically, anesthetic considerations in gastro esophageal reflux disease, esophageal carcinoma, esophageal perforation, and a variety of other esopha geal disorders will be discussed.

Anatomy of the Boerhaave syndrome

BACKGROUND

Spontaneous rupture of the esophagus (Boerhaave syndrome) occurs almost invariably at the same anatomic site. A weakness of the distal esophageal wall is suspected but has not been confirmed by anatomic studies. The aim of this work was to determine the existence of a structural abnormality in the esophageal wall.

MATERIAL AND METHODS

In six fresh human cadavers, the left lung was removed and the esophagus was insufflated in situ with air until it burst. The mucosa of the specimens was stripped off, allowing the fibers of the inner muscular coat to be seen. In addition a specimen from a patient who died from this cause was submitted to the same procedure.

RESULTS

The site of the experimental rupture matched the clinical case. The tear was located at the margin of contact between "clasp" and oblique fibers, and extends upwards.

CONCLUSIONS

The connective tissue of the junction between clasp and oblique fibers appears to constitute a weak point in the lower esophagus.

Spontaneous perforation of the cervical oesophagus

A case of spontaneous perforation of the cervical oesophagus is presented. It appears to be the tenth such case in the world medical literature, and the first to be reported from the Southern Hemisphere. The need for awareness of this pathologic entity is stressed, and cold water polydipsia is suggested as a diagnostic marker.

[Spontaneous rupture of the esophagus]

Eighteen patients (16 men and two women), aged 20 to 77 years, were admitted to the University hospital between 1973 and 1984 for a Boerhaave's syndrome. Fourteen over eighteen were more than forty years old. Other particular features were the frequency of alcoholism (11 patients) and the lack of preexisting gastrointestinal symptomatology. The cardinal symptom, pain, occurred in 17 cases. It was preceded in 10 subjects by vomiting. Subcutaneous emphysema was only found in five patients, but standard chest X-ray showed seven times a pneumomediastinum. Pleural effusion was present in 14 subjects. Thirteen patients underwent thoracotomy: five within 48 h (1 death) and eight after 48 h (4 deaths); two further deaths were due to withholding surgery, and a third by performing bipolar oesophageal exclusion at a late stage (8th day); six of these deaths were related to local infection. The clinical and radiological features of Boerhaave's syndrome are presented in a review of the literature; particular attention is paid to the various methods of treatment.

Spontaneous rupture of the oesophagus

A case of death due to spontaneous rupture of the oesophagus is reported. Few similar cases have been previously reported. In some the oesophageal wall had been weakened by previous ulceration or scarring. In this case there was no history or postmortem evidence of such damage. Under certain circumstances postmortem rupture of the oesophagus could occur and should be distinguished from antemortem rupture.