An unusual presentation of Boerhaave Syndrome: a case report

Presentation of Boerhaave's syndrome as an upper-esophageal perforation associated with a right-sided pleural effusion: A case report

BACKGROUND

Spontaneous esophageal rupture or Boerhaave's syndrome is a rare and acute disease with a high incidence of misdiagnosis and mortality. Here, we aimed to explore the clinical characteristics, diagnosis, treatment, and prognosis of spontaneous esophageal rupture, and to analyze the causes of misdiagnosis during the treatment of spontaneous esophageal rupture.

CASE SUMMARY

The clinical features of the patient with spontaneous esophageal rupture misdiagnosed earlier as pleural effusion were retrospectively analyzed and the reasons for misdiagnosis are discussed based on a current review of the literature. The patient was admitted to a local hospital due to shortness of breath accompanied by vomiting and abdominal distension for five hours. Based on the computed tomography (CT) scan analysis, clinically, right pleural effusion was diagnosed. However, the patient was unwilling to undergo right closed thoracic drainage. The patient also had intermittent fevers against infection, and during the course of treatment, he complained of chest pain, following which, he was transferred to our hospital. Grapefruit-like residue drainage fluid was observed. Re-examination of the chest CT scans suggested the presence of spontaneous perforation in the upper left esophagus. Therefore, the patient underwent an urgent esophageal hiatus repair. Unfortunately, the patient died of infection and respiratory failure due to progressive dyspnea after surgery.

CONCLUSION

Spontaneous esophageal rupture is a rare disease associated with high fatality. The patients do not present typical clinical symptoms and the disease progresses rapidly. This case report highlights the importance of a dynamic review of chest CT scan, not only for the initial identification of segmental injury but also for prioritizing subsequent treatment strategies. Moreover, we have presented some clues for clinicians to recognize and diagnose spontaneous esophageal rupture at rare sites (upper-esophageal segment) through this case report of spontaneous esophageal rupture that caused the patient's death. We have also summarized the reasons for the misdiagnosis and lessons learned.

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.

Transition of a Mallory-Weiss syndrome to a Boerhaave syndrome confirmed by anamnestic, necroscopic, and autopsy data: A case report

RATIONALE

Spontaneous esophageal rupture (Boerhaave syndrome) is a rare, though frequently fatal, event. It is generally caused by a sudden increase in pressure inside the esophagus. In some cases, full-thickness perforations of the esophagus may develop from previous lesions that initially involve only the esophageal mucosa (Mallory-Weiss syndrome) and which, following further triggering events, give rise to a transmural lesion.

PATIENT CONCERNS

Here, we present the case of a 45-year-old subject who suddenly died of acute cardio-respiratory failure, an autopsy was performed to identify the cause of death.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

The autopsy examination revealed a full-thickness rupture of the esophageal wall. Through the integration of necroscopy findings, anamnestic data, and histopathological examination, it has been possible to establish that complete esophageal rupture resulted from the evolution of a previous partial lesion of the esophageal wall, and that an untreated Mallory-Weiss syndrome evolved into a rapidly fatal Boerhaave syndrome.

LESSONS

This case shows that distal esophageal tears, rather than constituting a distinct entity, may be part of a spectrum of diseases and that a partial lesion of the esophageal wall caused by barogenic injury may evolve into a full-thickness rupture following further barotraumas.

Thoracoscopic esophageal repair with barbed suture material in a case of Boerhaave's syndrome

A 53-year-old man was referred to our hospital with Boerhaave's syndrome. Thirty hours after onset, a left thoracoscopic operation was performed, with carbon dioxide pneumothorax and the patient in right semi-prone position. The thoracic cavity was copiously irrigated with physiological saline and a 4-cm longitudinal rupture was identified on the left side of the lower esophagus. The esophageal injury was repaired in 2 layers by using barbed absorbable suture material. The patient was allowed oral feeds after contrast esophagography confirmed the absence of contrast leak at the sutured site on postoperative day 7, and discharged by day 28. Suturing of the ruptured esophagus under thoracoscopic guidance is considered to be difficult and requires expertise. This case report demonstrates that the use of a barbed suture material simplifies thoracoscopic esophageal repair and also highlights the importance of pneumothorax and patient position in improving access to the esophagus.

Diagnosis and treatment of Mallory-Weiss syndrome: Our experience with 64 cases

AIM: To explore the diagnosis and treatment of Mallory-Weiss syndrome (MWS).

METHODS: A retrospective analysis was performed of 64 MWS patients treated at our hospital from January 2010 to March 2014. The causes, endoscopic findings, treatment and prognosis were evaluated according to a new type of clinical classification.

RESULTS: The male to female ratio was 3.3∶1 and the average age was 50.2 years old. Approximately 53.1% of MWS cases were caused by over-drinking or inappropriate diet occasionally, 37.5% caused by underlying gastric diseases such as peptic ulcer (26.6%), gastric cancer (6.3%) or Dieulafoy's disease (4.7%), and 9.4% by endoscopic examination or treatment. 62.5% of MWS cases developed only one lesion of the cardia and/or lower esophagus and 29.7% developed two to three lesions. The lesions may occur in any location of the wall of the cardia and/or lower esophagus, with the right wall being a relatively common location (32.5%). According to a new type of clinical classification introduced here based on endoscopic examination, 17.2% of MWS cases were found to have active bleeding (type A) such as spouting, pulsating or oozing, 21.9% with a fresh blood clot (type B) and 32.8% with an old blood clot (type C). The rest (28.1%) was found to have linear ulcer or scar (type D). All type A patients were treated by endoscopic clipping, and some patients additionally underwent noradrenalin spraying. Some type B patients were treated by clipping or noradrenalin spraying. Only one type A patient died because of suspected underlying intestinal bleeding, and all other patients were cured.

CONCLUSION: Underlying gastric diseases are important causes of MWS and easy to be ignored, especially Dieulafoy's disease. Endoscopic clipping is the first choice of treatment for MWS, and the new type of clinical classification is useful for disease evaluation.

Mallory-Weiss Tear during Esophagogastroduodenoscopy

Mallory-Weiss tears (MWTs) are mucosal lacerations caused by forceful retching and are typically located at the gastroesophageal junction. Reported cases of MWT with serious complications seen in esophagogastroduodenoscopy are limited. We report MWT in an 81-year-old woman who presented with gastric perforation by esophagogastroduodenoscopy. We discuss and indicate that hiatal hernia, atrophic gastritis and old age may be associated with the gastric perforation in comparison to typical tears occurring at the gastroesophageal junction.

A lesson in clinical findings, diagnosis, reassessment and outcome: Boerhaave's syndrome

A man in his 30s presented with a brief episode of vomiting, acute abdominal pain and subsequent development of shortness of breath. On initial examination and investigation, the clinical impression was of a right-sided pneumothorax, pneumonia and pleural effusion. Early antibiotic treatment and management showed a clinical improvement, with the patient reporting resolution of his symptoms. This episode was short lived, with a further deterioration in his condition and worsening of symptoms. Ensuing examination, imaging and investigations demonstrated an oesophageal leak into the right pleural cavity. Following urgent stabilisation measures and insertion of a chest drain, he underwent successful surgical repair. Boerhaave's syndrome is an emergency situation, requiring quick recognition, diagnosis, aggressive treatment and management to optimise a good outcome.

Mallory-Weiss tear during gastric endoscopic submucosal dissection

A 78-year-old woman was referred to our department for treatment of an early gastric cancer. Esophagogastroduodenoscopy (EGD) demonstrated a flat elevated lesion and a polypoid lesion on the greater curvature of the antrum. Histological analysis of, endoscopic biopsy samples taken from these lesions revealed an adenocarcinoma and a hyperplastic polyp, respectively. ESD was conducted for removal of the lesions. Carbon dioxide (CO₂) instead of room air was used for insufflation, and the patient was adequately sedated without struggling or vomiting during the treatment. No significant bleeding from the lesion was observed during ESD, but fresh blood was identified endoscopically. Surprisingly, a Mallory-Weiss tear with active bleeding was detected on the lesser curvature of the gastric corpus. A total of eight hemoclips were applied for hemostasis. Both lesions were completely removed en bloc, and no bleeding or perforation developed after ESD. Histologically, the first lesion was a papillary carcinoma limited to the mucosal layer and without lymphovascular invasion or involvement of the surgical margins, while the second lesion was a benign hyperplastic polyp.