Case summary: Thanks to our multi-disciplinary ICU team for showering us with pearls today on a 55M with a PMH of esophagitis complicated by ulcerations and stricture s/p multiple dilations, EtOH abuse, who initially presented after a fall while intoxicated and symptoms of UGIB and was found to have esophageal rupture (Boerhaave’s syndrome!) and bilateral Candida empyema!
1. This patient got a CT scan after presenting with signs of UGIB, which is not routinely part of the diagnostic work-up. Importantly, patients with prior stricture/dilations and other esophageal instrumentation and/or anatomic abnormality are at increased risk of Boerhaave’s and thus warrant a CT scan if any suggestive symptoms.
2. UGIB is not a classic symptom of Boerhaave’s; more common are retrosternal chest pain after wretching, creptius of chest wall due to pneumomediastinum, odynophagia, dyspnea and shock.
3. When you rupture your esophagus, caustic pharyngeal and gastric contents leak everywhere and can cause mediastinitis, pleural effusion, pericarditis/tamponade, ARDS and shock.
4. Management of Boerhaave’s is a great mix of medicine and surgery and involves: 1) pharyngeal decompression, 2) gastric decompression, 3) endoscopic stenting, 4) drainage or debridement of mediastinal/pleural/pericardial fluid collections or areas of necrosis, 5) lung protective ventilation given high incidence of ARDS, and 6) esophageal surgical reconstruction 4-6 weeks later.
Crash course in Boerhaave’s syndrome/Effort rupture of the esophagus
- We were so lucky to have the fantastic Dr. Jan Horn (part-time VA ICU attending, part-time ZSFG trauma surgeon!) to teach us about Boerhaave’s from the surgical perspective.
- Interesting factoids:
- We learned today that Boerhaave’s is really hard to spell on the board in front of a crowd! In true old-school-doctor-fashion, Hermann Boerhaave, Professor of Medicine at Leiden University, named it after himself. The case he described was of Baron Jan van Wassenaer, a Dutch admiral, who liked to vomit after feasting so that he could feast more, ruptured his esophagus, and lived less than a day afterward.
- It can happen with a normal esophagus and after intense vomiting/wretching or anything else that causes a sudden increase in intraesophageal pressure (childbirth, seizure, prolonged coughing, weightlifting).
- History of stricture/ulcerations/dilations, as well as eosinophilic esophagitis, medication-induced esophagitis, Barrett’s esophagus, caustic ingestions, or infectious ulcers can also predispose.
- Usually the L posterolateral aspect of the distal intrathoracic esophagus (near the G-E jxn) but can be in the neck or sub-diaphragmatic.
- Classic: excruciating retrosternal chest pain (can be superior or inferior depending on location of rupture)
- 25 to 45% of patients have no history of vomiting
- May have crepitus on palpation of the chest wall due to subcutaneous emphysema.
- mediastinal crackling with each heartbeat may be heard on auscultation (Hamman’s sign)!
- can develop odynophagia, dyspnea, and sepsis
- pleural effusion
- pericardial effusion and tamponade
- sepsis/multi-organ failure
- Diagnosis: established by contrast esophagram or computed tomography (CT) scan.
- Extremely high mortality (25-50% in some series)
- The mainstay of treatment is to bypass the rupture such that pharyngeal and gastric contents can’t contaminate the thorax and treat any pre-existing sites of leakage. This involves:
- NPO, sometimes a tube-like device that drains the pharynx
- NG tube (very complex to place!) and ultimately G-tube
- Endoscopic stenting
- Source control +/- antibiotics for sites of contamination like the pleura (in this case, the patient had bilateral pleural effusions and yeast on a gram stain and got bilateral chest tubes), pericardium, mediastinum
- Given the high incidence of ARDS, many patients require lung protective ventilation.
- Esophageal surgical reconstruction 4-6 weeks later.
- Thanks to the fantastic Dr. Horn for describing how difficult/impossible it is to operate on these patients immediately given the necrosis and friability of their thoracic tissues
- Here are some fun pictures!
(1) Pneumomediastinum 2) Mediastinal widening, air, pleural effusions