SESSION TITLE: Critical Care Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Boerhaave's syndrome is a rare spontaneous esophageal perforation that can be catastrophic without prompt treatment.
CASE PRESENTATION: A 55 year-old-man with history of hypertension and peripheral vascular disease presented to an outside hospital complaining of epigastric pain and shortness of breath. He was found to have fever (38.3 C) and bilateral pulmonary crackles on physical exam. He quickly developed respiratory failure and sock requiring intubation and pressors. He was treated with empiric IV antibiotics for septic shock and was transferred to our hospital for higher level of care. Upon arrival, he had leukocytosis (10.1 x 109 cells/L) and normal hemoglobin and hematocrit. A chest x-ray showed bilateral diffuse pulmonary opacities and a small right hydropneumothorax. A right chest tube was placed with initial return of turbid fluid and after a few minutes it had drainage of what appeared to be edible mushrooms. The pleural fluid analysis showed a pH of 7.2, LDH of 2811 U/L and amylase of 4065 U/L. An esophagogram showed leak of contrast through the distal esophagus. The patient underwent an emergent thoracotomy for repair of esophageal rupture which had to be aborted, since dissection of the posterior mediastinum was considered very difficult to perform due to severe inflammation and adhesions in the area. The patient is currently under treatment in the ICU with a very guarded prognosis. Of note, the patient's family disclosed a history of alcohol abuse and vomiting that was not initially revealed by the patient.
DISCUSSION: Boerhaave's syndrome is caused by a sudden increase in intraesophageal pressure along with negative intrathoracic pressure. It is commonly associated with alcoholism and frequent retching and vomiting, risk factors that were present in our case but were not disclosed by the patient. The chest x-ray usually demonstrates mediastinal air, subcutaneous emphysema and widened mediastinum, however, our report is an example of how these features can be absent in this study. CT of the chest and contrast esophagogram have better diagnostic yields. The treatment for some patients can be conservative if they present with contained leaks, however, in the presence of a free perforation and sepsis, surgery should be performed emergently within the first 24 hours. Mortality is significantly increased if surgical treatment is delayed.
CONCLUSIONS: Boerhaave's syndrome can present without its classic findings in the chest x-ray and patients can withhold important information for its diagnosis (such as a history of alcoholism), therefore, a high index of suspicion is required for its diagnosis.
Reference #1: Carrott PW Jr, Low DE. Advances in the management of esophageal perforation. Thorac Surg Clin. 2011;21(4):541-55.
DISCLOSURE: The following authors have nothing to disclose: Carlos Martinez-Balzano, Bentley Makkar, Omair Chaudhary
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