Boerhaave's Syndrome

You are the cardiothoracic surgery CT1 asked to see a 48-year old, overweight, man who developed severe retrosternal chest pain after eating a large meal then vomiting copiously. The referring doctor tells you that he currently has a temperature of 38.5. How would you proceed?

Example answer introduction

I suspect that this gentleman may have Boerhaave syndrome, a ruptured oesophagus as a result of forceful vomiting. I would assess this patient using an A-E approach, take a focused history and perform a thoracoabdominal examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

I would ask about:

  • Allergies

  • Medications 

  • Past medical history - oesophagitis, Barret’s oesophagus, recent upper GI endoscopy, infections ulcers.

  • Last meal

  • Events leading up to this point - nature of pain, nausea and vomiting, 

Examination

Thoraco-abdominal examination

  • Inspect – chest wall movements, abdominal distention, surgical/traumatic scars

  • Auscultate – Hamman’s sign, diminished or absent bowel sounds

  • Palpate – surgical emphysema, tenderness, guarding, peritonism, rebound tenderness

  • Percussion – Dull, Resonant or hyper-resonant 

Example questions to progress the station

Q1 - You find him to be floridly septic and continues to complain of chest pain. What investigations would you order. 

 

I would consider:

  • Urine dip 

  • Abdominal x-ray – Evidence of bowel obstruction

  • Erect chest x-ray – Air under diaphragm signifying perforated viscus. 

  • Ultrasound abdomen – gallstones, bile duct dilatation

 

 

Q2 - The chest X-ray shows a widened mediastinum and pneumomediastinum with a normal abdominal examination. What does this indicate and how would you proceed?

 

I would instigate treatment for a suspected perforated oesophagus.

Initial management

  • IV antibiotics according to local protocol 

  • Analgesia according to the WHO pain ladder

  • Proton-pump inhibitor

  • IV crystalloids to maintain urine output of 0.5ml/kg/hr 

  • Keep nil-by-mouth

  • Inform the Cardiothoracic Registrar to review the patient – this patient will need water-soluble contrast swallow if stable and CT thorax and abdomen. 

  • VTE Prophylaxis

  • Keep patient and any relatives informed

  • Document, document, document!!!

 Escalation
I would ensure that I discussed with my registrar. 
Discussions are likely to take place with:
- Cardiothoracics
- Intensive care
- Anaesthetics
- Theatres
Notes:
Perforation of the oesophagus can occur in the cervical, thoracic or abdominal segments. Cervical perforations may be managed conservatively if the leak is confined and there are no signs and symptoms of sepsis. Thoracic and abdominal perforations are approached via thoracotomy and laparotomy respectively. Boerhaave syndrome is almost 100% fatal if not managed surgically therefore prompt recognition and management is essential.
Useful Resources

Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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