Description:
This is the case of 41 year old men with active chronic alcoholism how was admitted to the ER complain nausea and vomiting in multiples occasion during the pass two days. Two hours before to the admission, he started with sever abdominal pain and bright red blood hematemesis.
Vital sign upon the arrival were blood pressure 90/60 HR: 110x. Laboratory result were Hb 9 mg/dL WBC 12,000 PLT: 350,000 Amylase: 29 LDH: 90 CPK: 20.
Plain chest radiography was performed to rule out stomach perforation.
During upper G.I. endoscopy, a hiatal hernia is found. A deep lesion at 5 o clock of the screen was identified showing a deep disruption of the esophageal wall includes the muscular layer and at 12 o’clock of the screen we found Mallory Weiss tear, and the other. Thoraco-abdominal CT scan with IV and Oral contrast was perform, observing in the distal esophagus the presence of air and contained fluid collection in the mediastinum.
Also air in the peritoneum cavity was found.
Over the next 12 hrs the patient featured inflammatory response syndrome, urgent surgery and a trans-hiatal repair of the defect were performed.
Boerhaave’s syndrome is a rare condition and represents a form of a barogenic rupture caused by the increase of the intraluminal pressure in the distal esophagus.
This syndrome is the most sinister cause of G.I. perforation with estimated mortality rates of 20–40%. The classical presentation of Boerhaave´s syndrome is vomiting, chest pain and subcutaneous emphysema, also call Mackler´s triad. Diagnostic errors are prevalent; the most common misdiagnosis is perforated ulcer, myocardial infarction, pulmonary embolism, dissecting aneurysm and pancreatitis. Treatment is base on NPO, antibiotic and surgery the transthoracic primary repair remain popular for patient who present in the first 24 hrs of the perforation. In the case of contained leak the conservative measures can be feasible especially if patients are diagnosed after 48 h of the perforation and no clinical signs of sepsis are evident.
Reference.
Boerhaave`s syndrome diagnosis and surgical management: Surgeon 2007:2007:5:39-44.
Spontaneous rupture of the esophagus: Boerhaave's Syndrome in 2008: Dig Surg 2009:26:1-6.
Contributed By:
Jose Alberto Gonzalez-Gonzalez, MD, Centro Regional de Enfermedades Digestivas, UANL, Monterrey, Mexico
Jonas Villareal, MD, Centro Regional de Enfermedades Digestivas, UANL, Monterrey, Mexico
Hector J. Maldonado, MD, Centro Regional de Enfermedades Digestivas, UANL, Monterrey, Mexico
