Rupturing Reality

Aravindthatchan.K1, T. Niveanthini Arun2

1Resident -Emergency Medicine, Kauvery Hospital, Alwarpet, Chennai

2Consultant – Emergency Medicine, Kauvery Hospital, Alwarpet, Chennai

Case presentation

A 87 year gentleman brought to our ER around 2:40pm with sudden onset of pain , scapular region, bilaterally, associated with sweating, from 2pm, Patient took T. Sorbitrate 5mg Sublingual at home and came here for further management.

  • Two episodes of vomiting since early morning, containing food particles, watery ,non bilious, non projectile and  not blood stained.
  • Two episodes of loose stools, watery in nature, not with blood or mucus, since early morning
  • Patient had sweets the previous night following which he had abdominal discomfort.
  • H/O cough with expectoration ,whitish color, since two days
  • No H/O chest pain , palpitation, breathlessness, orthopnea, fever, loss of consciousness, giddiness, decreased urinary output.

Past Medical History

sHTN, left leg residual polioparalysis

Last Creatinine – 2.3

No drug/food allergies

Not a smoker or addicted to alcohol

On Examination

On arrival, patient was conscious, oriented, afebrile, hydration fair

PICKLE – Negative (Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy, and Edema)

B/L pitting Edema +

Vitals

  • HR – 72/min, BP – 110/60 mmhg, RR – 26/min, SpO2 – 69% in RA
  • CBG – 174
  • GCS – E4V5M6 (15/15)
  • Temp – 2 °f

Systemic examination

  • CVS – S1S2 +, no murumur, JVP – normal
  • RS – B/L AE +. NVBS, no added sounds
  • PA – soft, non tender, no organomegaly, BS +
  • CNS – moving all 4 limbs
  • L/E – B/L scapula region tendrness + R>L

Treatment at ER

Propped up position/IV Access

Started with 2L O2 via nasal prongs, maintaining        SpoO2 >94%

IV cannula secured –

The following drugs were administered

  • Inj Paracetamol 1g iv stat
  • Inj Pantoprazole 40mg iv stat
  • Inj Emeset 8mg iv stat

Patient re assessed after 20 in view of persistent pain – Inj morphine 2mg IV stat give

Investigations advised: ECG, Chem-8, Trop-I,   Echo

ECG was not diagnostic

Chem8
TROP I 0.01 (Negative)
Na136
K4.0
Cl101
Glucose 191
BUN29
Creatinine2.5
Hb9.9,
Hct29%

ECHO Report

  • Dilated LA
  • Mild MR
  • Posterior mitral annular calcification
  • RWMA + – distal septum & LV apex mildly hypokinetic
  • Normal LV systolic dysfunction (EF- 55%)
  • No PE
  • X-Ray Chest

Impression

B/L Subcutaneous Emphysema,  Left side pleural effusion

Pneumomediastinum

CT Chest

Impression

  • Extensive pneumomediastinum with gas around the great vessels
  • Subcutaneous emphysema in left axillary and cervical region
  • Suspected perforation with focal contrast leak adjacent to left posterolateral wall of esophagus just above gastro – esophageal junction
  • B/L moderate pleural effusion with subsegmental atelectatic changes
  • Features suggestive of distal esophageal rupture

Endoscopy

Borehaave syndrome – fully covered  self-expandable metallic stent insitu

Course in the Hospital

  • Patient was then admitted to ccu started on IV antibiotics, PPI, antiemetic, nebulisation, mucolytic agent, fluid resuscitation and oxygen support
  • CTVS opinion obtained for respiratory distress and pleural Left side ICD placed and removed
  • Medical Gastroenterologist opinion obtained, endoscopy done showed Borehaave Syndrome-fully covered SEMS in situ.
  • Repeat CT Abdomen showed stent in situ and mediastinal collection
  • He had Paroxysmal Atrial fibrillation, started on Inj Cardone and Dopamine IV infusion
  • ICU team opinion obtained for breathlessness. In view of resolving mediastinitis, antibiotics were added
  • Increase in Procalcitonin,C-Reactive protein, Creatinine, NT-ProBNP noted
  • Nephro opinion obtained for decreased urine output and elevated creatinine, started on Inj Lasix infusion
  • In view of worsening renal function, he was advised Hemodialysis, Right IJV – HD Catheter placed, Patient had cardiac arrest after initiating Hemodialysis, approximately in 20minutes
  • Patient intubated, ROSC obtained, had atrial fibrillation
  • pH-7.07, started on Inj Sodium Bicarbonate IV stat followed by infusion. SLED initiated, on ventilation
  • Patient went into cardiac arrest and could not be revived

Discussion

Boerhaave Syndrome

Spontaneous oesophageal rupture resulting from sudden increased intra-oesophageal pressure.

Most commonly associated with emesis with incomplete cricopharyngeal relaxation

Clinical Features

  • 80% cases in middle age men
  • Commonly associated with binge eating, and  over – indulgence in alcohol
  • Occurs typically after forceful vomiting/retching
  • Other precipitants – childbirth, coughing, seizures, weight lifting, blunt trauma
  • Followed by severe chest pain (lower thoracic/upper abdomen)
  • Swallowing may aggravate pain and precipitate a coughing spell
  • Associated with SOB and/or pleuritic pain
  • Haematemesis uncommon

Pathophysiology

  • Barogenic injury to lower oesophagus
  • Sudden increase oesophageal intraluminal pressure against a closed cricopharyngeus muscle
  • Hydrostatic pressure overcomes the oesophageal tensile strength
  • Tear in left posterolateral oesophageal wall,2- 3cm proximal to the GE junction with leak into left pleural cavity

Physical findings

Macklers triad (50%)

  • Vomiting
  • Lower thoracic pain Subcutaneous Emphysema

Hamman’s crunch: Due to air in the mediastinum (20%)

Pleural effusion: Usually left sided, thoracentesis – undigested food and gastric juice, SOB, fever, tachycardia, hypotension, abdomen pain

Diagnosis

  • Esophagogram: A fluoroscopic X-ray with contrast dye (esophagram) is usually the first choice when Boerhaave’s syndrome is suspected; it’s quick and noninvasive with a high level of accuracy
  • CT scan
  • Endoscopy: may aid in the diagnosis of Boerhaave syndrome, it is generally not recommended due to the risk of extending the esophageal tear through insufflation or direct trauma

Treatment

IV fluids. Most people need immediate IV fluid resuscitation due to overall volume loss.

Antibiotics. A broad spectrum of antibiotics will   be given intravenously to control infection.

Surgical repair. Surgery is the standard of care for most people. Ideally, the rupture should be repaired directly within 24 hours. Depending on condition, minimally invasive surgery technique like video-assisted thoracoscopic surgery (VATS).

Some emergency cases may need to be managed by open thoracotomy to allow quick and thorough access to full thoracic cavity.

Drainage/debridement: In addition to the direct repair of the tear, any infected fluid collections in the cavity will need to be drained and sterilized, and any infected or necrotic (dead) tissue will need to be removed. In some severe cases, this may mean removing part of esophagus.

Advanced management: When surgery isn’t possible within 24 hours of rupture, direct repair may not work. The edges of the wound may have begun to stiffen. In that case, may need to remove part or all of your esophagus (esophagectomy). If need an esophagus replacement, can have one after six weeks.

Alternative nutrition: While your esophagus is healing, you won’t be able to use it to swallow food, so you’ll need an alternative way of feeding. This might be by tube or by vein.

References

  • Lieu MT, Layoun ME, Dai D, Soo Hoo GW, Betancourt J. Tension hydropneumothorax as the initial presentation of Boerhaave Respir Med Case Rep. 2018;25:100-103.[Abstract]
  • van der Weg G, Wikkeling M, van Leeuwen M, Ter Avest E. A rare case of oesophageal rupture: Boerhaave’s Int J Emerg Med. 2014;7:27. [Abstract]
  • Wilson RF, Sarver EJ, Arbulu A, Sukhnandan R. Spontaneous perforation of the esophagus. Ann Thorac 1971 Sep;12(3):291-6. [Abstract]
  • Tonolini M, Bianco R. Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography. J Emerg Trauma 2013 Jan;6(1):58-60. [Abstract]
  • Carrott PW, Low Advances in the management of esophageal perforation. Thorac Surg Clin. 2011 Nov;21(4):541-55. [Abstract]
  • Ivey TD, Simonowitz DA, Dillard DH, Miller Boerhaave syndrome. Successful conservative management in three patients with late presentation. Am J Surg. 1981 May;141(5):531- 3.[Abstract]
  • Hauge T, Kleven OC, Johnson E, Hofstad B, Johannessen Outcome after stenting and débridement for spontaneous esophageal rupture. Scand J Gastroenterol. 2018 Apr;53(4):398-402. [Abstract]
  • Barakat MT, Girotra M, Banerjee S. (Re)building the Wall: Recurrent Boerhaave Syndrome Managed by Over-the-Scope Clip and Covered Metallic Stent Dig Dis Sci. 2018 May;63(5):1139-1142. [Abstract]
  • Chen YH, Lin PC, Chen YL, Yiang GT, Wu MY. Point-of-Care Ultrasonography Helped to Rapidly Detect Pneumomediastinum in a Vomiting Medicina (Kaunas). 2023 Feb 17;59(2) [Abstract]
  • Wiggins B, Banno F, Knight KT, Fladie I, Miller J. Boerhaave Syndrome: An Unexpected Complication of Diabetic Ketoacidosis. Cureus. 2022 May;14(5):e25279. [Abstract]
  • Kakar N, Smith HC, Shadid AM. Prolonged Emesis Causing Esophageal Perforation: A Case Cureus. 2022 May;14(5):e24720.[Abstract]

 

Dr. Niveanthini

Dr. T. Niveanthini Arun
Consultant – Emergency Medicine

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