Boerhaaves Syndrome Spontaneous esophageal rupture was described by

Boerhaave’s Syndrome • "Spontaneous" esophageal rupture was described by Boerhaave in 1724. – Dutch admiral Baron John von Wassenauer overindulged on roast duck and wine, subsequently vomited/died – Autopsy revealed gastric contents in pleural space – at the time surgery was considered “a fools venture”

Herman Boerhaave 1668 -1738 • Dutch physician, botanist, chemist, medical educator, philosopher – self taught medicine – attended dissections but not lectures – married daughter of a rich merchant – did lectures for $ – treated rich and famous – insisted on autopsies – bedside teaching – did consults by mail – Never had a bad hair day

Boerhaave’s Syndrome • Classic triad – vomiting, – excruciating chest pain – subcutaneous emphysema

CXR • Left pleural effusion/ left hydropneumothorax in 12 to 24 hours. • Pulmonary infiltrates • Sub. Q air • Widened mediastinum

Boerhaave’s Syndrome • Anatomy – perf of esophagus -> mediastinum – negative pressure promotes soilage – 90% tears along the left, posterolateral wall of the distal esophagus – role of esoph. disease is ? • Etiology – retching against a closed glottis • also laughing, childbirth, sz, trauma, heavy lifting • most common cause upper endoscopy (~60%)

Causes • • • Endoscopy (~60%) Dilations NG tubes Neck/abd Surgery Post emetic Infection • • Blunt trauma Caustics Foreign body Esoph disease

Boerhaave’s Syndrome Clinical features -may be delayed! • Pain, (pleuritic, back, chest, abd) • Dyspnea • Subq Air/ mediastinal air • Hamman’s crunch (systolic) • • Vomiting Dysphagia Change in voice Sepsis

Boerhaave’s Syndrome • Treatment – ABCs – NPO – Antibiotics/fluids – Consultation • Outcome – survival 65 -90% – poor survival w/ delayed dx >48 hrs

Boerhaave’s Syndrome • Diagnosis – often difficult – 1/3 presentations are atypical – Differential dx • • • Spont. Mediastinum Thoracic Aortic Aneurysm PE PUD Pancreatitis Mesentaric ischemia

Follow up • Pt underwent thoracotomy, repair • Episode of lidocaine toxicity in the ICU • Discharged home