Boerhaave syndrome

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Boerhaave syndrome (also called Boerhaave's syndrome) is rupture of the esophagus. It is generally caused by excessive vomiting in eating disorders such as bulimia although it may rarely occur in extremely forceful coughing or other situations. It can cause pneumomediastinum and/or mediastinitis (air or inflammation of the mediastinum) and sepsis. This condition was first documented by Herman Boerhaave after whom it is named.

1 Symptoms
2 Pathophysiology
3 Treatment
4 Notes
5 References

[edit] Symptoms

It typically occurs after forceful vomiting. Boerhaave syndrome is a transmural perforation (full-thickness; a hole) of the esophagus, distinct from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting. Because it is generally associated with vomiting, Boerhaave syndrome usually is not truly spontaneous. However, the term is useful for distinguishing it from iatrogenic perforation, which accounts for 85-90% of cases of esophageal rupture, typically as a complication of an endoscopic procedure, feeding tube, or unrelated surgery.

The classic Meckler's triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases. The most common chest radiograph findings in spontaneous esophageal rupture (SER) are pleural effusion (91%) and pneumothorax (80%). The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema. Up to 12% of patients with SER may have a normal chest radiograph. Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases.^[1]

[edit] Pathophysiology

Esophageal rupture in Boerhaave syndrome is thought to be the result of a sudden rise in internal esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of the cricopharyngeus muscle (a sphincter within the esophagus) to relax. The syndrome is commonly associated with the consumption of excessive 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 before the stomach.

[edit] Treatment

Its treatment includes immediate antibiotic therapy to prevent mediastinitis and sepsis, surgical repair of the perforation, and if there is significant fluid loss it should be replaced with IV fluid therapy since oral rehydration is, obviously, not possible.

[edit] Notes

^ S. Herman, H. Shanies, H. Singh & M. Warshawsky: "Spontaneous Esophageal Rupture: Boerhaave's Syndrome," pages 177-182. Clinical Pulmonary Medicine 10(3), May 2003