Boerhaave's syndrome presenting as tension pneumothorax.

Abstract

Boerhaave's syndrome can present inidaily as a case of tension pneumothorax. Mortality rate with delayed treatment is very high, therefore diagnosis should be made rapidly in the emergency department. Multidisciplinary cooperation, immediate radiological confirmation, prompt aggressive resuscitation, and surgical intervention offer the best chance of survival. (7AccidEmergMed 1999;16:235-236) Keywords: Boerhaave's syndrome; tension pneumothorax; multidisciplinary cooperationCase report A 72 year old women was brought to the accident and emergency department of the Chelsea and Westminster Hospital by ambulance in respiratory distress. The previous night she had experienced epigastric pain for about four hours; this culminated in an episode of vomiting 10 hours before presentation that exacerbated her epigastric and retrosternal pain. She became alarmed and called an ambulance when increasing dyspnoea supervened. She was quickly assessed in the resuscitation room and found to be in profound respiratory distress and peripheral vascular collapse. Her respiratory rate was 30 breaths/min, pulse rate 120 beats/min, thready but regular, temperature 36°C, oxygen saturation on 15 1/min via a rebreathing mask 93.2%, and blood pressure 90/50 mm Hg. Chest examination, arterial blood gas analysis, and electrocardiography were done simultaneously revealing left tracheal deviation, surgical emphysema in the neck, hyper-resonant percussion note, absent breath sounds on the right hemithorax, metabolic acidosis, and sinus tachycardia.A diagnosis of tension pneumothorax was made and the right hemithorax decompressed immediately with a size 1 4G special chest aspiration trochar inserted into the second intercostal space mid-clavicular line. This was followed by aspiration via a three way stopcock that yielded about 500 ml of air. Consequently, her dyspnoea improved significantly allowing a quick mobile post-aspiration chest radiograph (fig 1), which showed 50% right hydropneumothorax, pneumomediastinum, and surgical emphysema in the neck.The diagnosis of spontaneous rupture of the oesophagus (Boerhaave's syndrome), complicated by tension pneumothorax, was then made.Her resuscitation was continued with intravenous infusion of colloids and under water seal pleural drainage with a size 28 ch (9.3 mm in diameter) tube inserted into the fifth intercostal space mid-axillary line. This instantly drained about 200 ml of bile stained fluid containing food debris with a pH of 6.0. At this stage the surgeons, radiologists, and anaesthetists were immediately involved. She was fasted, had nasogastric intubation with suction, intravenous antibiotics (cefuroxime 1500 mg and metronidazole 500 mg), and urethral catheterisation. Central venous pressure monitoring was started and an arterial line inserted.

A Rare Case of Boerhaave Syndrome Presenting with Right Tension Pneumothorax and Review of the Literature

“…Boerhaave syndrome has been recognized in the medical literature to present in unusual ways, however presentation with tension pneumothorax is exceedingly rare. There is only one previously reported case in North America, and 5 cases worldwide [10][11][12][13][14]. In contrast to our case, all of these cases reported history of preceding abdominal pain and vomiting, alerting the physicians to the possibility of esophageal rupture as the source of the pneumothorax.…”

Boerhaave's syndrome – tension hydropneumothorax and rapidly developing hydropneumothorax: two radiographic clues in one case

“…Therefore, tension pneumothorax in these cases should be interpreted as tension hydropneumothorax. In our case, the first chest radiograph only showed a small pneumothorax because lung markings were clearly visible, and the visceral edge in the upper left hemithorax could be identified with the great caution. Therefore, if we recognized tension hydropneumothorax on chest radiograph at the time of admission, Boerhaave's syndrome should be investigated and established before the patient worsens.…”

Simultaneous bilateral spontaneous pneumothoraces in a patient with occupational asthma

“…With the smoking history and presence of emphysematous changes on the CT scan, there was a clinical suspicion that he may have elements of COPD and this would warrant further investigations on follow-up. Another rare but potentially life-threatening differential diagnosis that must be considered in such presentations is Boerhaave's syndrome 13 14. This is of relevance in our patient as he had an episode of vomiting and a history of partial oesophagectomy, but it was confidently excluded after conducting a CT with oral contrast.…”