Spontaneous Esophageal Rupture: Boerhaave's Syndrome

A case of rapid diagnosis of Boerhaave syndrome by thoracic drainage

BACKGROUND

Boerhaave syndrome is a rare and often fatal syndrome. Delayed diagnosis and treatment is closely associated with prolonged morbidity and increased mortality. In general, esophagography is usually chosen as the diagnostic procedure, but it has a relatively high false-negative rate. There are no reports, to our knowledge, regarding the efficacy of thoracic drainage, although it is easier to perform and more immediate than esophagography in the emergency department.

OBJECTIVES

To report the efficacy of thoracic drainage for rapid diagnosis and treatment of Boerhaave syndrome.

CASE REPORT

An 80-year-old woman was admitted with vomiting and sudden onset of postprandial chest pain radiating to the back. Initially, myocardial infarction or aortic dissection was suspected, but was excluded by point-of-care tests and computed tomography (CT) scan, which revealed a left-sided pneumothorax, heterogeneous left pleural effusion, and pneumomediastinum at the lower level of the esophagus. Boerhaave syndrome was suspected and confirmed by thoracic drainage, which drained off bloody fluid and residual food such as broccoli. Emergency thoracotomy was performed within 4 h after onset of symptoms. The patient made an uneventful recovery.

CONCLUSION

Findings in this case indicate that chest pain, left-sided massive effusion on chest radiography, and left-sided massive heterogeneous effusion on CT scan are important for the diagnosis of Boerhaave syndrome. Subsequent thoracic drainage is useful for confirming Boerhaave syndrome, and such a strategy might lead to a good prognosis for patients with this rare but critical disease.

Spontaneous esophageal rupture: analysis of 11 cases

AIM: To investigate the clinical characteristics, diagnosis, treatment of spontaneous esophageal rupture.

METHODS: The clinical data for 11 patients with spontaneous esophageal rupture treated from 1995 to 2009 at West China Hospital of Sichuan University were collected. The clinical characteristics, diagnosis and treatment of spontaneous esophageal rupture were retrospectively analyzed.

RESULTS: All patients were male and had clear causes for the disease. Primary clinical symptoms include chest pain (9 patients), chest tightness (6 patients), abdominal pain (6 patients), and subcutaneous emphysema (3 patients). Of the 11 patients, 1 abandoned treatment, 4 received esophageal repair, 2 received jejunostomy, 1 received gastrostomy and jejunostomy, 1 received esophagogastric anastomosis, and 2 received endoscopic stent implantation; 10 were cured or showed improvement. Of 7 patients followed up, 2 died within 6 mo after discharge from hospital, 3 had acid reflux and difficulty swallowing, and 2 had no complications.

CONCLUSION: Early and accurate diagnosis is important for the treatment and prognosis of spontaneous esophageal rupture. Endoscopic treatment is a promising approach for spontaneous esophageal rupture.

Identifying Chest Pain Emergencies in the Primary Care Setting

The majority of patients presenting to a primary care physician with acute chest pain will have non-life-threatening etiologies. Nevertheless, catastrophic cause of chest pain such as ACS, AD, PE, esophageal perforation, and pericarditis must be considered in the differential diagnosis. Often, these deadly conditions have atypical clinical presentations that must be recognized. Furthermore, the physical examination can be deceptively benign in patients harboring a catastrophic etiology of chest pain. By identifying these atypical presentations, recognizing the utility of the physical examination, and understanding of the limitations of traditional diagnostic imaging, primary care physicians can effectively diagnose patients who have life-threatening cause of acute chest pain.