Boerhaave s Syndrome

1. Boerhaave’s Syndrome Ri ???

2. Esophageal perforation Incidence & Cause Endoscopic procedures are the most common, especially in reflux oesophagitis, postoperative stenosis, or achalasia Fiberoptic endoscopy 0.09% Rigid endoscope 0.07% with dilation 0.25% *most common at cricopharyngeus muscle

3. Esophageal perforation Other cause Forceful hydrostatic or pneumatic dilatation for achalasia Esophageal cancer: Celestin plastic tubes passed transorally through an unresectable carcinoma of the esophagus as a palliative procedure Varices: Sengstaken&Blakemore tubes and Linton tubes for tamponade of esophageal varices Traumatic endotracheal intubation: generally in the dorsal midline at an area of weakness (Lannier’s triangle) External trauma: penetrating or blunt injuries Foreign body intake

4. Esophageal perforation Symptom & Sign Symptom: vomiting, pain, hematemesis, dysphagia, dyspnea Sign: tachycardia, fever, subcutaneous emphysema, chest hypersonarity or dullness, infection, sepsis

5. Esophageal perforation Diagnosis Plain chest radiography: pneumomediastinum, subcutaneous emphysema, mediastinal widening, air-fluid level in mediastinum Contrast esophagography with water-soluble contrast medium: site of leakage, confined to mediastinum or communicated to pleural or peritoneal cavity CT scan: used when the presentation is atypical Esophagoscope: rare

8. Esophageal perforation Management Conservative treatment: massive antibiotic therapy IV hydration NPO nasogastric drainage total parenteral nutrition

9. Esophageal perforation Management Operative treatment: Absolute indications for emergency operation are the presence of hydropneumothorax, pneumoperitoneum, empyema, systemic sepsis, shock, and adult respiratory distress syndrome. The surgical option: drainage alone suture repair esophagectomy ~followed by re-establishment of gastrointestinal continuity by a left colon bypass or oesophagogastrostomy esophageal exclusion ~by division at cardia and at neck the use of plastic-covered self-expanding metallic stents

10. Esophageal perforation Prognosis A reported mortality estimate is approximately 35%, making it the most lethal perforation of the GI tract. The best outcomes are associated with early diagnosis and definitive surgical management within 12 hours of rupture If intervention is delayed longer than 24 hours, the mortality rate (even with surgical intervention) rises to higher than 50% and to nearly 90% after 48 hours.

11. Boerhaave’s syndrome Origin First described by Dutch physician, Herman Boerhaave, in 1723. His patient was Baron Jan von Wassenaer, Grand Admiral of the Dutch Fleet and Prefect of Rhineland who vomited after a meal and developed left-sided chest pain and died 18 hours later. At post mortem the following were found: a tear of the left posterior wall of the oesophagus 5 cm above the diaphragm, emphysema, food in the left pleural space.

12. Boerhaave’s syndrome Introduction Esophageal rupture in Boerhaave syndrome is postulated to be the result of a sudden rise in intraluminal esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of the cricopharyngeus muscle to relax. The syndrome commonly is associated with overindulgence in food and/or alcohol. The most common anatomical location of the tear in Boerhaave syndrome is at the left posterolateral wall of the lower third of the esophagus, 2-3 cm proximal to the gastroesophageal junction.

13. Boerhaave’s syndrome vs Mallory-Weiss Syndrome The only thing which distinguished Boerhaave's syndrome, from Mallory Weiss is the depth of the laceration. The Mallory-Weiss tear is superficial whereas the Boerhaave tear may rupture the wall. In both, barring Boerhaave's initial case in which the esophagus was completely avulsed from the stomach, the tears are parallel to the long axis of the esophagus. 

14. Boerhaave’s syndrome Cause With postemetic spontaneous perforations of the oesophagus Not truly spontaneous. However, the term is useful for distinguishing it from iatrogenic perforation, which accounts for 85-90% of cases of esophageal rupture. Forceful protracted vomiting Significant blunt chest trauma During CPR This condition is much more common in the patient with a pre-existing esophageal disease such as reflux esophagitis.

15. Esophageal perforation, anastomotic leaks, and strictures The role of prostheses GR. Mason, M.D. American Journal of Surgery Volume 181 . Number 3 . March 2001