Boerhaave Syndrome

An 85-year-old white woman was brought to the emergency department (ED) with acute, severe left posterolateral chest wall pain of several hours' duration. The nonradiating pain was accompanied by shortness of breath. She denied palpitations, diaphoresis, syncope, or dizziness.

The patient reported several recent falls that caused no immediate pain. She had no symptoms of upper respiratory tract infection and no recent changes in her appetite, bowel movements, or sleep patterns. She denied abdominal pain but reported a few episodes of dry heaving and vomiting over the past few days. Two weeks before admission to the hospital, she experienced increasing lower extremity edema, which had resolved by the time she presented to the ED.

The medical history included hypertension, chronic renal insufficiency, Alzheimer dementia, depression, osteopenia, transient ischemic attacks, and chronic anemia. She denied regular tobacco or alcohol use. Her past surgical history was significant for a left total knee replacement.

Drs Omar Mendez, John Pezzullo, and Marianne Mustafa and Mr David Foster of Schenectady, NY, noted that the patient was in obvious pain but in no acute respiratory distress. Her initial blood pressure was 210/96 mm Hg; oxygen saturation on room air, 94%; heart rate, 140 beats per minute; respiratory rate, 18 breaths per minute; and temperature, 36.6°C (97.8°F). Multiple ecchymoses were seen over the posterior chest wall, the right knee, and the left maxillary region. Findings from the remainder of the head, ear, eye, nose, and throat examinations were unremarkable, as were the evaluations of the abdomen and the extremities.

The neck was supple, with no bruits or jugular venous distention. Lungs were clear except for decreased breath sounds at the left base. Palpation of the anterior chest wall detected diffuse tenderness over the left posterior ribs, particularly over ribs 5 and 6. There was no crepitus or obvious deformity. Heart rate was tachycardic; no murmurs, gallops, or rubs were present. Rectal examination was guaiac negative. The patient was alert and oriented but had poor long- and short-term memory.

The white blood cell (WBC) count was 8800/µL; hemoglobin, 10.3 g/dL; hematocrit, 30.2 mL/dL; platelet count, 298,000/µL; sodium, 134 mEq/L; potassium, 5.4 mEq/L; chloride, 104 mEq/L; and carbon dioxide, 19.5 mEq/L. Blood urea nitrogen level was 113 mg/dL; creatine, 4.2 mg/dL; glucose, 196 mg/dL; amylase, 180 U/L; cholesterol, 282 mg/dL; and lactate dehydrogenase, 286 U/L. Tests for creatine kinase isoenzymes and troponin were negative. The ECG demonstrated sinus tachycardia with premature atrial contractions. The initial chest film (A) showed a small left pleural effusion and a small left apical pneumothorax.

After several hours, the patient became increasingly tachypneic and hypoxic. Her oxygen saturation dropped to 88% on room air; respiration rate was greater than 30 breaths per minute. She also had an episode of coffee ground emesis. The patient was transferred to the ICU; a second chest film demonstrated an increasing hydropneumothorax (B).

A chest tube drained more than 1000 mL of dark brown material. Analysis of the pleural fluid revealed low pH; WBC count of 19,500/µL; red blood cell count, 6000/µL; glucose level, 0 mg/dL; protein, 3.5 g/dL; lactate dehydrogenase, 3263 U/L; amylase, 1040 U/L; and cholesterol, 84 mg/dL. The suspected diagnosis of Boerhaave syndrome was confirmed by a barium swallow and upper GI endoscopic examination.

Boerhaave syndrome, or spontaneous perforation of the esophagus, is a rare condition that can occur after a sudden increase in intra-abdominal pressure; persistent vomiting was the likely cause in this patient. Coughing, retching, heavy lifting, or childbirth also may incite the syndrome. Most perforations occur at the distal esophagus within a few centimeters of the diaphragm on the left side. The incidence is 5 times greater in males than in females.

Patients with this condition usually complain of the sudden onset of retrosternal pain or pain in the left shoulder or left side of the chest. They also may present with abdominal pain. Objective findings of Boerhaave syndrome include fever, tachypnea, and possible shock. Chest radiographs often show pleural effusions, pneumomediastinum, pneumothorax, or subcutaneous emphysema. Confirm the diagnosis with an upright chest film, an esophagogram, or a barium swallow.

Surgery with primary closure and external drainage is the usual treatment. Conservative therapy-including parenteral feeding, intravenous antibiotics, and nasogastric suction-is appropriate for persons at high risk for perioperative complications, such as this patient.

FOR MORE INFORMATION:

• Quick G. What's wrong with this picture? Consultant 2000;40:1269-1272.