Boerhaave Syndrome, the spontaneous rupture of the esophagus is a rare condition which carries a high mortality rate. Definitive treatment is surgical repair. Mortality is usually caused by mediastinitis, pericarditis, pneumonitis and empyema leading to sepsis and shock.
A 38 year old man presented with complaints of vomiting coffee ground vomitus, epigastric pain and dyspnea. On examination he was pale, ill and tachycardic but blood pressure remained stable. There were reduced breath sounds over the left side and abdomen was tender and tense. Sepsis was clearly evident by leukocytosis, high BUN and metabolic acidosis; low hemoglobin signified considerable blood loss. Chest X-ray noted a hydropneumothorax over the left side. Nasogastric and thoracostomy tube drained coffee ground contents. The diagnosis of Boerhaave syndrome was confirmed with an OGDS revealing a perforation just above the cardioesophageal junction. Despite aggressively resuscitated with fluids, transfusion of blood products, started on broad spectrum antibiotic and admitted to ICU, He was clearly moribund within hours and a plan for surgical intervention failed to materialize due to his deteriorating condition. He succumbed after 2 days.
Boerhaave sydrome is a spontaneous transmural perforation of the esophagus commonly involving the left side of the lower esophagus just above the diaphragm. The diagnosis of this condition is often challenging. In this patient although Mackler’s triad was absent, the diagnosis was established by a history of forceful emesis with signs clearly demonstrating communication between the esophagus and the pleural cavity. His condition was critical and prognosis was guarded on presentation as he was in severe sepsis compounded by significant blood loss. Even with prompt treatment and surgery i.e. thoracotomy, lavage and repair of esophagus, patient outcome would have been poor.
Boerhaave syndrome is invariably fatal without intervention. It should be promptly diagnose and aggressively treated to prevent mortality.