BOERHAAVE SYNDROME

Abstract

Introduction

Boerhaave syndrome is also known as spontaneous esophageous rupture or effort rupture of the oesophagus is a rare case. Although the actual incidence of oesophageal perforation worldwide is unclear, some studies estimate incidence of approximately 3.1 per 1,000,000 per year.

Case Presentation

We presented a case of 79 years old male with underlying hypertension, dyslipidaemia and ischaemic heart disease with complaint of severe epigastric and central chest pain. Blood pressure was 60/40 on arrival and ECG showed ST depression at V2 and V3.Patient was treated initially as ACS in cardiogenic shock. Subsequent assessment after pain subsided with IV morphine revealed reduced breath sound and guarded abdomen. Chest X-ray showed left haemopneumothorax with left lung collapse. Left thoracostomy tube was placed with immediate drainage of 300 mls of billous fluid mixed with food content. CT thorax and abdomen findings revealed an evidence of contrast leak at lower oesophagus. Surgical team proceeded with OGDS which confirmed a large oesophageal perforation at distal oesophagus.

Discussion and conclusion

Classically patient with Boerhaave syndrome will present as Mackler triad of vomiting, lower thoracic pain and subcutaneous emphysema but this is rare which may lead to a delay in diagnosis. Making the diagnosis of Boerhaave syndrome is a difficult clinical challenge due to varying mode of presentation of the disease .With the main complaint of chest pain and ECG changes, this patient initially was treated as ACS. Even after reviewed the chest tube output we still considered the possibility of malposition of chest tube.Diagnosis can be difficult because of non-specific sign and symptom of the disease. Inspection of chest tube drainage is important as a fast and efficient way to clinically diagnose Boerhaave syndrome in patients without obvious external trauma. Complication is very minimal with open method chest tube insertion.