Overview
Definition:
Boerhaave syndrome is a spontaneous, transmural esophageal rupture, typically occurring after forceful vomiting or retching, leading to mediastinitis and sepsis.
Epidemiology:
Rare condition, incidence estimated at 1 in 10,000 hospital admissions
More common in males, typically between 50-70 years old
Often associated with alcohol abuse or binge eating.
Clinical Significance:
A surgical emergency with high mortality if not promptly diagnosed and treated
Understanding operative management is crucial for surgical residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
Sudden onset severe retrosternal chest pain
Vomiting or retching preceding pain
Dyspnea and tachypnea
Hematemesis or hemoptysis
Subcutaneous emphysema in the neck or chest
Fever and sepsis signs.
Signs:
Tachycardia and hypotension
Subcutaneous crepitus (Hamman's crunch)
Mediastinal widening on chest X-ray
Signs of shock and sepsis
Diminished breath sounds.
Diagnostic Criteria:
Mackler's triad (vomiting, chest pain, subcutaneous emphysema) is suggestive but not always present
Definitive diagnosis relies on imaging and endoscopic confirmation of esophageal perforation.
Diagnostic Approach
History Taking:
Detailed history of emesis, preceding events, chest pain character, duration, and associated symptoms
Alcohol intake, prior esophageal pathology, and anticoagulant use are important.
Physical Examination:
Assess for signs of hemodynamic instability
Palpate for subcutaneous emphysema
Auscultate for Hamman's crunch and diminished breath sounds
Assess for abdominal tenderness.
Investigations:
Chest X-ray: Mediastinal widening, pleural effusion, pneumomediastinum
Contrast esophagography (Gastrografin or water-soluble contrast): Highly sensitive for detecting leak
CT scan: Delineates extent of perforation, mediastinitis, and abscesses
Esophagogastroduodenoscopy (EGD): Can confirm perforation but carries risk of worsening the tear
usually performed after initial imaging.
Differential Diagnosis:
Myocardial infarction
Pulmonary embolism
Aortic dissection
Boerhaave syndrome
Mallory-Weiss tear (mucosal tear, not transmural)
Peptic ulcer perforation
Acute pancreatitis.
Management
Initial Management:
Immediate resuscitation: IV fluids, oxygen, broad-spectrum antibiotics (covering oral flora and gut organisms), analgesia
Nasogastric tube decompression
Nil per os
Transfer to a facility capable of surgical intervention.
Medical Management:
Broad-spectrum IV antibiotics are crucial to combat mediastinitis
Early administration is vital
Antiemetics if vomiting persists
Pain control with IV analgesics.
Surgical Management:
Surgical repair is the mainstay for Boerhaave syndrome
Indications: Transmural perforation, hemodynamic instability, failure of endoscopic management, significant contamination
Procedures: Thoracotomy with esophageal repair (primary closure with or without buttressing with pleura/diaphragm/gastric flap), esophagectomy with cervical esophagostomy and gastrostomy (in extensive or delayed cases), or esophageal diversion
Thoracic drainage is always performed.
Supportive Care:
Nutritional support via parenteral nutrition or jejunostomy feeding
Close monitoring of vital signs, fluid balance, and sepsis markers
Chest tube management and monitoring of output
Wound care for thoracotomy incision.
Complications
Early Complications:
Mediastinitis
Sepsis and septic shock
Respiratory failure
ARDS
Anastomotic leak (if primary repair)
Bleeding.
Late Complications:
Esophageal stricture
Esophageal dysmotility
Tracheoesophageal fistula
Recurrent perforation
Chronic pain syndrome.
Prevention Strategies:
Prompt diagnosis and surgical intervention
Aggressive antibiotic therapy
Careful surgical technique with adequate repair and coverage
Early institution of nutritional support
Postoperative vigilance for signs of leak or infection.
Prognosis
Factors Affecting Prognosis:
Time to diagnosis and treatment is the most critical factor
Extent of esophageal injury
Presence of comorbidities
Degree of mediastinal contamination and sepsis
Patient's overall condition.
Outcomes:
Mortality rates remain high (20-50%), particularly with delayed treatment
Early surgical repair within 24 hours significantly improves survival
Survival rates decrease substantially with each passing day.
Follow Up:
Regular outpatient follow-up is essential
Esophagography or manometry may be required to assess esophageal function and rule out strictures
Long-term nutritional monitoring and management of any sequelae.
Key Points
Exam Focus:
Boerhaave syndrome is a spontaneous esophageal perforation
Time to surgery is paramount
Operative choices include primary repair, repair with buttressing, or esophagectomy
Broad-spectrum antibiotics are critical.
Clinical Pearls:
Always suspect Boerhaave syndrome in a patient with sudden severe chest pain after forceful vomiting
Gastrografin esophagography is the investigation of choice for suspected perforation
Early surgical consultation is mandatory.
Common Mistakes:
Delaying surgical intervention
Misdiagnosing as cardiac event or pulmonary embolism
Inadequate antibiotic coverage
Failure to consider esophageal rupture in a patient with a history of vomiting and chest pain.