2 min read - Boerhaave's Syndrome
A 32 years old patient came with vomiting for one day after outside food consumption. He had vomited about 20 times during the last couple of hours. He complained of upper abdominal pain due to repeated vomiting. He had several episodes of cough and developed shortness of breath. Xray was taken to exclude aspiration.
What would you do?
This Xray on the first glance looks quite normal. But when you closely have a look you might see some abnormality in the right upper zone. However, if you look even more closely you will pick that there are some streaky air shadows along both sides of the trachea.
This is pneumomediatinum.
In the context of vomiting you will have to consider the possibility of esophageal rupture. Which has the fancy name 'Boerhaave Syndrome'.
What are the other features?
A classical sign would be surgical emphysema. That is not a sign you should ever miss.
Do you really have to know this? It should be rare isn't it?
Rare indeed. But in Sri Lanka, rare things are not uncommon! In my short medical career I have seen two of them!
If you see this what should you do?
This is life threatening. So the patient need highly specialized care. Until the patient is transferred, he should be kept absolutely nil orally. Never attempt NG intubation. Start IV proton pump inhibitors and broad spectrum antibiotics.
What are the management options?
Minimally symptomatic patients with no features of sepsis could be observed while being kept nil oral. All the others will need surgical repair and in some cases esophagectomy.
What happened to the two patients you saw?
One patient in fact had achalasia cardia which predisposed the rupture. That patient was severely septic at presentation and the management team could not save her.
The other one was managed conservatively. She made a complete recovery.
During my internship one well built gentleman admitted with severe chest pain. ECGs were repeatedly normal, cxr on admission was normal too. We didn't have 2DE at DGH NE those days. Pt deteriorated rapidly. ABG showed severe acidosis. Pt was intubated and ventilated and transferred to ICU. at that point relatives pointed out that he had a bout of vomiting last night after consuming alcohol. Cxr repeated at icu showed pneumomediastinum and oesophageal rupture diagnosed. Pt was air-lifted to a private hospital in Colombo. Later heard that the pt passd away.
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