Boerhaave Syndrome / Oesophgeal Rupture

Boerhaave Syndrome is described as spontaneous rupture of the oesophagus that typically occurs following vomiting where there is a sudden increased intraoesophageal pressure with a negative intrathoracic pressure.

Only 10% of cases occur following vomiting and majority (More than 55%) is iatrogenic which occurs due to medical instrumentation (Endoscopy, etc…)


Boerhaave syndrome is associated with high mortality and morbidity and can be fatal without treatment. 

Diagnosis of Boerhaave syndrome is often difficult because of the non specific nature of symptoms.


It is important differentiate this from Mallory-Weiss syndrome which is a non transmural / partial thickness tear (Involving mucosa and submucosa) of the oesophageal wall, on the other hand Boerhaave syndrome is a transmural / full thickness tear of the oesophagus. 


Incidence : 3.1 /1 million per year



Pathophysiology Of Boerhaave Syndrome


Vomiting

       ↓
Sudden increase in the intraluminal pressure of the oesophagus
       ↓
Neurological incoordination leading to failure of opening the upper end of oesophagus 
(Failure to relax cricopharyngeus muscle)
       ↓
Rupture of the oesophageal wall 


Commonest site of rupture

  • Left posterolateral wall of the lower third of the esophagus
  • 2-3 cm proximal to the gastroesophageal junction



Causes Of Boerhaave Syndrome

  • Alcoholism
  • Bulimia / Overeating


Difference Between Boerhaave Syndrome And Mallory-Weiss Syndrome



Clinical Presentation Of Boerhaave Syndrome


  1. Repeated vomiting
  2. History of alcohol consumption / overeating
  3. Sudden onset of severe chest pain, may radiate to the back or to the left shoulder
  4. Pain and coughing on swallowing
    • Due to the communication between the oesophagus and pleural cavity 
  5. Haematemesis is not typical feature in a rupture but seen commonly in Mallory-Weiss syndrome 
  6. Mackler’s triad – Classical presentation 
    • Chest pain
    • Vomiting
    • Subcutaneous emphysema
  7. Majority of cases have a non specific presentation which leads to a delay in diagnosis
  8. Tachypnoea
  9. Features of pleural effusion 
  10. Hamman crunch 
    • A crackling sound on chest auscultation
    • Occurs due to pneumomediastinum
  11. Later stage – Sepsis
    • Fever
    • Tachycardia
    • Hypotension
 
Diagnosis Of Boerhaave Syndrome
 
  1. Initial tests
    • FBC
      • Leukocytosis
    • Chest X-Ray
      • Unilateral pleural effusion
      • Air in mediastinum or peritoneum
      • Mediastinal widening
      • Subcutaneous emphysema
  2. Confirmed by
    • Oesophagography
      • Better than CT scan 
      • Gastrografin is used as contrast as barium can cause severe mediastinitis
    • CT scan
      • Used in patients who cannot tolerate oesophagography



Treatment Of Boerhaave Syndrome

  • Surgery is the mainstay of treatment
  • There is a scope for conservative management
    • Oesophageal rupture is confined to the mediastinum
    • Cavity should be drained back into the esophagus
    • Minimal symptoms
    • No evidence of sepsis
 
Surgical management
  1. Fluid resuscitation
  2. IV broad spectrum antibiotics
  3. Surgical intervention



Conservative management

  1. NBM
  2. Nasogastric suction
  3. IV broad spectrum antibiotics
  4. Fluid resuscitation
  5. Insertion of a draining tube – Tube thoracostomy 
  6. Nutrition supplementation – Jejunostomy feeding  

   

Latest posts by Dr. Pasindu Suriapperuma (see all)
5 1 vote
Article Rating
Subscribe
Notify of
guest
0 Comments
Inline Feedbacks
View all comments