oesophageal rupture or perforation including Boerhaave syndrome

see also:

• gastroenterology

• oesophageal rupture or perforation is a rare potentially life threatening condition

• Boerhaave syndrome
  • spontaneous rupture or perforation of oesophagus due to severe straining or vomiting
    • approx. a third do not have a history of vomiting
    • typical patient is a middle aged man vomiting after dietary or alcohol excess
  • most have a normal oesophagus but some have underlying conditions such as eosinophilic oesophagitis (EoE), oesophagitis in adults, oesophageal ulcers
• erosive perforations
  • button batteries
  • oesophageal ulcers
• iatrogenic following endoscopy

• these depend upon location, degree of leakage and time since injury
• usually have severe retrosternal chest pain
• if the perforation is in the cervical oesophagus, then neck pain, dysphagia or dysphonia may be features
• those with intra-abdominal oesophageal perforation will tend to have epigastric pain radiating to shoulder and/or back, worse on lying flat, and present with a rigid abdomen due to abdominal sepsis
• some present with sudden onset catastrophic haematemesis due to aorto-oesophageal fistula formation
• in a minority of patients, the following may also be present but do take hours to present:
  • subcutaneous emphysema
  • Hamman's sign if there is pneumomediastinum - crackling on auscultation with each heart beat
  • pleural effusion
• usually within hours features of mediastinal or abdominal sepsis develop:
  • sepsis / septicaemia
  • SOB, fever, hypotension, etc

• early diagnosis is crucial
• delays to diagnosis increase mortality substantially - overall mortality is said to be up to 50%
• erect CXR +/- neck Xray will often show pneumomediastinum or free gas under diaphragm (if intrabdominal perforation)
• Gastrografin swallow, although less sensitive, is preferred initially over a barium swallow as gastrografin is water soluble and causes less mediastinal inflammation if there is rupture or perforation
  • sensitivity of barium swallow is said to be 90% for intrathoracic perforations but only 60% for cervical perforations
• CT chest/abdomen
  • the preferred Ix if either gastrografin/barium is not possible (eg. uncooperative patient), or free gas under diaphragm
  • highly sensitive for extravasated contrast or air but is poor at localisation of the perforation
  • possible CT findings include:
    • oesophageal wall oedema and thickening
    • fluid or gas bubbles outside oesophagus wall
    • mediastinal widening
    • air or fluid in pleural spaces, retroperitoneum or lesser sac
• endoscopy is generally avoided as it may increase air into mediastinum or may cause further damage

• see the adult patient with chest pain in the ED - in particular ACS, aortic dissection, PE, pneumothorax

• nil orally for at least 7 days
• resuscitative measures as per sepsis / septicaemia
  • IV cannula
  • bloods as per sepsis
  • broad spectrum IV antibiotics
  • IV proton pump inhibitors (PPIs)
• early diagnosis as above
• early referral to surgery for possible drainage of any collections
• consideration for endoscopy in select situations