Boerhaave's syndrome presenting as a mid-esophageal perforation associated with a right-sided pleural effusion

A rare case of Boerhaave syndrome with cervico-thoracic esophageal junction rupture causing bilateral empyema; case report from Nepal

INTRODUCTION AND IMPORTANCE

Boerhaave syndrome is a rare finding where spontaneous rupture of esophagus occurs, usually in distal segment. It is a life threatening condition that requires urgent surgical intervention.

CASE PRESENTATION

We present a case of 70 years male who presented with pleural effusion and later empyema following spontaneous rupture of cervico-thoracic junction of esophagus who was managed successfully with primary surgical repair.

CLINICAL DISCUSSION

Although Boerhaave syndrome is tricky to diagnose but it should be considered in all cases with a combination of gastrointestinal and pulmonary signs and symptoms.

CONCLUSION

Clinical correlation along with imaging such as HRCT chest or gastrografin study is required to come to a diagnosis, however surgical intervention should not be delayed to reduce the mortality.

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

INTRODUCTION

Boerhaave's syndrome is a life-threatening oesophageal perforation that carries a high mortality rate (20-50%). Diagnosis is difficult by its rarity and the absence of typical symptoms. Treatment of this condition usually requires surgical intervention.

PRESENTATION OF CASE

We report the case of a 77-year-old man that resorted to the emergency room with dyspnoea and thoracic pain after vomiting. CT scan revealed pneumomediastinum, left collapse lung and loculated pleural effusion. A left intercostal chest tube was inserted with food drainage. Hence, Boerhaave's syndrome was suspected. Thoracotomy with mediastinum debridement, pleural drainage and oesophageal T-tube drainage was performed. Patient was admitted on the Intensive Care Unit with septic shock, with need for ventilatory support and vasopressor therapy. Two days later, a second look thoracotomy was done with definitive oesophageal repair and pleural patch. The post-operative course was complicated by pneumonia and stroke. Patient was discharged home on the 38th day and remains well at 3 month of follow-up.

DISCUSSION

Delayed diagnosis and treatment are the principal causes of high mortality in Boerhaave's syndrome. The classic Mackler's triad (vomiting, lower thoracic pain and subcutaneous emphysema) is present in less then 50% of cases. A thoracic drainage may be useful to confirm diagnosis promptly. There is no standard treatment option. In this case report, the authors used a damage control approach to control sepsis, allowing for a delayed definitive oesophageal repair.

CONCLUSION

Prompt diagnosis with thoracic drainage and a damage control treatment plan might lead to good prognosis for patients with this rare and potentially fatal condition.

Successful stenting of four spontaneous oesophageal perforations in a single patient during a 3-year period

Spontaneous oesophageal perforation, a rare condition associated with high mortality due to mediastinitis and multi-organ failure, can be treated surgically or with endoscopic stents. We present a case of four right-sided oesophageal perforations during a 3-year period in a single patient, all successfully stented. The 51-year-old Caucasian male had his first oesophageal perforation in 2012, which was successfully treated with a fully covered endoscopic stent. No residual pathology was seen at stent removal. Two years later, the patient was successfully treated with stents twice for recurrent perforations. The fourth spontaneous perforation at the same site occurred this fall, and again endoscopic treatment was successful. The patient does not report any squeals. In spite of the successful outcome, we would like to emphasize the need for close surveillance and readiness for definitive surgical treatment.