A rare case of oesophageal rupture: Boerhaave's syndrome

Spontaneous pneumomediastinum: A comprehensive review of diagnosis and management

Pneumomediastinum is a rare condition defined by the presence of air in the mediastinum. In the absence of traumatic injury, iatrogenic injury, or clear etiology, it is called spontaneous pneumomediastinum (SPM). Spontaneous pneumomediastinum most commonly occurs in younger individuals and has a self-limiting course with a good outcome. The purpose of the present manuscript is to systematically review the existing literature on SPM evaluation and management for updated clinical understanding of this condition. A literature search was conducted of publications about SPM on MEDLINE/PubMed and Google Scholar by identifying all the articles with key search terms "pneumomediastinum" and "spontaneous pneumomediastinum". Inclusion criteria were case series published in English between 1980 and 2023. In total, 24 case series were selected and reviewed to determine presenting symptoms, clinical signs and predisposing factors associated with spontaneous pneumomediastinum. Most patients were male; the average age at diagnosis was 26.3 years. The most common presenting symptoms were chest pain and dyspnea. The most common exam finding was subcutaneous emphysema, in 35.4% of patients. Only 5.9% had the classic Hamman's sign. Risk factors include history of asthma, history of smoking, and recent physical activity. This manuscript presents an extensive review of relevant literature highlighting the diagnosis and essential management of spontaneous pneumomediastinum.

High risk and low prevalence diseases: Esophageal perforation

INTRODUCTION

Esophageal perforation is a rare but serious condition associated with a high rate of morbidity and mortality.

OBJECTIVE

This article highlights the pearls and pitfalls of esophageal perforation, including diagnosis, initial resuscitation, and management in the emergency department based on current evidence.

DISCUSSION

Esophageal perforation occurs with injury to the layers of the esophagus, resulting in mediastinal contamination and sepsis. While aspects of the history and physical examination may prompt consideration of the diagnosis, the lack of classic signs and symptoms cannot be used to rule out esophageal perforation. Chest radiograph often exhibits indirect findings suggestive of esophageal perforation, but these are rarely diagnostic. Advanced imaging is necessary to make the diagnosis, evaluate the severity of the injury, and guide appropriate management. Management focuses on hemodynamic stabilization with intravenous fluids and vasopressors if needed, gastric decompression, broad-spectrum antibiotics, and a thoughtful approach to airway management. Proton pump inhibitors and antifungals may be used as adjunctive therapies. Current available evidence for various treatment options (conservative, endoscopic, and surgical interventions) for esophageal perforation and resulting patient outcomes are limited. A multidisciplinary team approach with input from thoracic surgery, interventional radiology, gastroenterology, and critical care is recommended, with admission to the intensive care setting.

CONCLUSIONS

An understanding of esophageal perforation can assist emergency physicians in diagnosing and managing this deadly disease.

Minimally Invasive Approach in Boerhaave's Syndrome: Case Series and Systematic Review

Introduction: Boerhaave's syndrome is a life-threatening spontaneous perforation of the esophagus associated with significant morbidity and mortality. Historically, thoracotomy has been the mainstay of treatment, but is associated with high morbidity and pain. Minimally invasive approaches provide alternative treatment possibilities. This systematic review together with inclusion of a case series from a tertiary esophagogastric unit assesses current evidence focused on minimally invasive surgical management of this condition. Methods: A systematic review was conducted in line with MOOSE (Meta-analyses Of Observational Studies in Epidemiology) guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles focusing on the minimally invasive management of Boerhaave's syndrome were identified and scrutinized. We also report demographics and outcomes for a consecutive case series of patients with acute Boerhaave's syndrome managed via thoracoscopy. Results: Fifteen studies were included comprising 5 retrospective cohort studies and 10 case reports. Management strategies were divided into three categories: thoracoscopic, endoscopic, and laparoscopic. Overall mortality rates for each treatment modality were 2%, 13%, and 33%, and treatment success rates 98%, 38%, and 67%, respectively. Postoperative infective complications were seen in 79% of patients, with only 2 patients requiring salvage thoracotomy. In our local case series, we report 4 consecutive patients managed with thoracoscopy, with a 100% treatment success rate. Conclusion: Minimally invasive approaches in the management of Boerhaave's syndrome are safe and effective. We propose a selective management algorithm involving a minimally invasive approach to management of this life-threatening condition. Registered with local clinical outcomes team as service evaluation. (Approval number sev/0171).

Life-threatening bleeding from dissecting Intramural Hematoma of Esophagus (IHE) treated by trans arterial embolization

Dissecting intramural hematoma of esophagus (DIHE) is an uncommon entity, characterized by accumulation of blood within the esophageal wall and usually managed conservatively. Only in rare circumstances, DIHE is associated with massive life-threatening hemorrhage requiring emergency treatment. We present a case of DIHE associated with cardiovascular collapse and treated by transcatheter arterial embolization. Transcatheter arterial embolization is a rare treatment option for DIHE associated with hemodynamic instability and only a handful of cases have been reported in the literature.

Clinical features of idiopathic esophageal perforation compared with typical post-emetic type: a newly proposed subtype in Boerhaave's syndrome

BACKGROUND

n our previous nationwide survey report on esophageal perforation, we proposed the existence of cases with idiopathic esophageal perforation at a certain rate.

AIMS

To elucidate the clinical characteristics of idiopathic esophageal perforation, we performed a comparative analysis between cases with idiopathic type and post-emetic type esophageal perforation.

METHODS

This study enrolled 139 patients with esophageal perforation (post-emetic type: idiopathic type = 115:24) as the subjects of nationwide survey on esophageal perforation. We conducted detailed studies on chief complaints, inflammatory responses, initial diagnosis, location and situation of the perforation site, time to therapeutic intervention, and prognosis between the two groups.

RESULTS

Compared with post-emetic type, cases of idiopathic type tended to exhibit rear-side perforation (p = 0.052) and significantly less presented chest pain (p = 0.002). Consequently, cases of idiopathic type significantly missed to diagnose as esophageal perforation compared with post-emetic type (p = 0.042). With regard to inflammatory response, cases of post-emetic type experienced hyperthermia compared with idiopathic type (p = 0.033). On the other hand, cases of idiopathic type exhibited significantly higher level of C-reactive protein than post-emetic type (p = 0.004). In addition, it took longer time until starting treatment in the cases of idiopathic type (p < 0.0001) and the cases of idiopathic type showed significantly worse prognosis than the cases of post-emetic type (p = 0.009).

CONCLUSION

This study first focused on the characteristics of idiopathic esophageal perforation that have been included in so-called Boerhaave's syndrome. The pathophysiology of the idiopathic type should be separately understood from post-emetic type, because the diagnostic and prognostic features largely differ.

Bee Sting to Boerhaave's Syndrome

Boerhaave's syndrome is a rare condition defined as the spontaneous rupture of the esophagus that generally occurs due to retching, forceful vomiting and sometimes even spontaneously. Atypical presentation often misleads the diagnosis leading to a delay in early intervention, and a strong clinical suspicion is indeed required to diagnose the condition. Definitive treatment being surgical repair, endoscopic intervention can be attempted in nonseptic patients.

How to cite this article: Kaladhar S, Nikilesh Kumar G, Misra KC, Hemanth C, Appasani S. Bee Sting to Boerhaave's Syndrome. Indian J Crit Care Med 2021;25(3):346–348.

[Spontaneous rupture of the esophagus in a patient with chronic obstructive pulmonary disease]

A case report of successful surgical treatment of spontaneous rupture of the esophagus in a patient with chronic obstructive pulmonary disease, bronchial asthma and obesity is presented. Rupture of the esophagus occurred during a coughing without vomiting.

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.

Imaging of Gastrointestinal and Abdominal Emergencies in Binge Drinking

Excess alcohol consumption is a leading cause of preventable morbidity and mortality globally. The pattern of consumption of alcoholic beverages has changed in our society in the recent past, with binge drinking becoming more and more common, especially among young adults. Abdominal pain following alcohol consumption can be secondary to a wide range of pathologies, the treatment algorithm of which can range from medical supportive treatment to more invasive life-saving procedures such as transarterial embolization and emergency laparotomy. Correct diagnosis, differentiation among these conditions, and implementing the correct management algorithm is heavily reliant on accurate and appropriate imaging. We review the pathophysiology, clinical presentation, imaging features and management options of acute abdominal emergencies secondary to binge drinking, based on a selection of illustrative cases.

Two-tube method for treatment of spontaneous esophageal rupture and concomitant mediastinal infection

Objective

Spontaneous esophageal rupture (SER) is a rare but life-threatening condition with high mortality. The prognosis of patients with SER treated with surgical intervention or the traditional “three-tube” method is controversial. Thus, the aim of this study was to evaluate the clinical efficacy, feasibility, and safety of a new “two-tube” method involving a trans-fistula drainage tube and a three-lumen jejunal feeding tube for the treatment of SER without concomitant pleural rupture.

Methods

From January 2007 to June 2016, patients with SER and managed with the “two-tube” method or other methods were retrospectively analyzed. Data collected included initial presentation, procedure time, duration of treatment, numbers of patients with eventual healing of leaks, and complications.

Results

The average procedure time for the “two-tube” method was 22.1 ± 5.5 minutes. In comparison with the control method, the “two-tube” method had a similar diagnosis time (3.6 ± 1.4 vs. 3.4 ± 1.4 days) but a significantly higher successful closure rate (94.4% vs. 63.6%) and shorter treatment time (38.2 ± 5.6 vs. 53.6 ± 16.9 days). No complications associated with performance of the “two-tube” method occurred.

Conclusion

The “two-tube” method is an effective and safe approach for patients with SER.

Successful Management of Delayed Esophageal Rupture with T-Tube Drainage Using Video-Assisted Thoracoscopic Surgery

Spontaneous perforation of the esophagus after forceful vomiting is known as Boerhaave syndrome, a rare and life-threatening condition associated with a high rate of mortality. The management of Boerhaave syndrome is challenging, especially when diagnosed late. Herein, we report the successful management of late-diagnosed Boerhaave syndrome with T-tube drainage in a 55-year-old man. The patient was transferred to our institution 8 days after the onset of symptoms, successfully managed by placing a T-tube, and was discharged on postoperative day 46 without complications.

An Unusual Case of Spontaneous Esophageal Rupture after Swallowing a Boneless Chicken Nugget

A 25-year-old previously healthy man presented to our Emergency Department with shortness of breath and epigastric pain after swallowing a boneless chicken nugget one hour prior to presentation. Physical examination revealed epigastric rigidity and tenderness. Serology was normal except for mildly elevated bilirubin and amylase. Computed tomography (CT) scan of the chest revealed a distal esophageal rupture with accompanying pneumomediastinum and left-sided pleural effusion. Treatment was initiated with administration of intravenous fluids and broad-spectrum antibiotics. Subsequently, an esophageal stent was inserted endoscopically in addition to VATS (Video-Assisted Thoracoscopic Surgery) drainage of the left-sided pleural space. This case illustrates an unusual presentation of Boerhaave's syndrome: a rare and life-threatening form of noniatrogenic esophageal rupture most often preceded by forceful vomiting. Our case demonstrates that physicians should maintain an index of suspicion for spontaneous esophageal rupture in patients presenting with shortness of breath and epigastric pain even in the absence of preceding vomiting, cough, or seizure. Additionally, ingestion of boneless, shell-less foods may be sufficient to cause rupture in individuals without underlying esophageal pathology. CT scan of the thorax and upper abdomen should be performed in these patients to rule out this rare and life-threatening diagnosis.

Boerhaave's syndrome in a patient with an upside down stomach: A case report

INTRODUCTION

Spontaneous esophageal perforation, or Boerhaave's syndrome, is a life-threating condition which usually requires emergent surgery. An upside down stomach is defined as a gastric volvulus in a huge supradiaphragmatic sac. In general, this condition can result in ischemia and perforation of the stomach. This is the first report of a patient with Boerhaave's syndrome and an upside down stomach.

CASE PRESENTATION

A 79-year-old woman presented with sudden epigastric pain following hematemesis. Evaluation of the patient showed both an esophageal perforation and an upside down stomach. Surgical drainage and irrigation of the mediastinum and pleural cavities were undertaken emergently. Due to the concurrent gastric volvulus, a gastrostomy was placed to fix and decompress the stomach. The patient had an uneventful hospital course and was discharged.

DISCUSSION AND CONCLUSION

Boerhaave's syndrome is a rare but severe complication caused by excessive vomiting, due to a sudden elevation in intraluminal esophageal pressure resulting in esophageal perforation. Acute gastric volvulus can result in ischemia and perforation of the stomach, but has not previously been reported with esophageal perforation. The most likely mechanism associating an upside down stomach with Boerhaave's syndrome is acute gastric outlet obstruction resulting in vomiting, and subsequent esophageal perforation. Perforation of the esophagus as well as perforation of the stomach must be considered in patients with an upside down stomach although both upside down stomach and Boerhaave's syndrome are rare clinical entities.

Exercise-induced pneumomediastinum

Background

A sudden onset of chest pain, which often reflects a life-threatening disease, requires prompt diagnosis in the emergency department.

Findings

A 12-year-old boy presented with sustained chest pain and dyspnea after diving into a swimming pool and was transferred to our emergency department. A chest examination noted a crunching and rasping sound at the precordium, synchronous with the heartbeat. Chest radiography showed lucent streaks and the mediastinal pleura at the left cardiac outline. Additionally, computed tomography showed massive pneumomediastinum surrounding the heart. Thus, he was diagnosed with spontaneous pneumomediastinum.

Conclusions

Spontaneous pneumomediastinum should be considered in the differential diagnosis of chest pain. In addition to medical history-taking, careful physical examination, which can identify the characteristic finding of a friction sound synchronous with the heartbeat (Hamman’s sound), will help in the immediate diagnosis of spontaneous pneumomediastinum.