Boerhaave Syndrome in an Elderly Man

Abstract

Boerhaave syndrome is rare, has an non-specific clinical presentation and most commonly develops after persistent vomiting. Septic shock dominates the clinical picture as a result of extensive infection of the mediastinum and pleural and abdominal cavities. The current management of Boerhaave syndrome includes conservative, endoscopic and surgical treatments. The authors present the case of a 94-year-old man admitted to hospital with community-acquired pneumonia with mild respiratory insufficiency complicated by oesophageal perforation after an episode of vomiting and the development of a large left pleural effusion. An endoscopic approach with the placement of an oesophageal prosthesis was chosen given the advanced age of the patient. The hospital stay was complicated by pleural effusion infection requiring broad-spectrum antibiotics and prosthesis substitution. The patient was discharged after 60 days of hospitalization, without the need for oxygen supplementation, and scoring 80% on the Karnofsky Performance Status Scale. The increase in average life expectancy requires a case-by-case approach, where the benefits of invasive manoeuvres and likelihood of discharge are weighed against an acceptable quality of life, aiming to prevent futile medical treatment.LEARNING POINTSBoerhaave syndrome is a complete rupture of the oesophageal wall secondary to a sudden increase in intraluminal oesophageal pressure, often in the lower third and left lateral position of the oesophagus.The management of Boerhaave syndrome depends on the time of diagnosis and clinical presentation and includes conservative, endoscopic and surgical approaches.Curative, aggressive approaches focused on the treatment of disease are often not appropriate for an aging population, hence the need for a case-by-case approach, where the benefits of invasive manoeuvres and likelihood of discharge are weighed against an acceptable quality of life, aiming to prevent futile medical treatment.

Transhiatal esophagectomy in Boerhaave syndrome – Case report and literature review

“…Blood and fluid samples are non-specific, although diagnostic thoracentesis can reveal food, increased amylase and pH below 6 [14] , [15] , [17] .…”

“…The diagnosis is confirmed with water-soluble contrast, so if there is clinical suspicion of BS this exam is mandated [5] , [8] , [14] , [18] , [19] , [20] . The chest radiography could show left-sided pleural effusion, lung infiltrates and atelectasis, but also pneumomediastinum and hydropneumothorax [2] , [17] .…”

“…BS management includes several options: conservative, endoscopic or surgical [9] , [14] , [17] . It needs to take into account time of diagnosis, extent of damage, local lesions and of patient status [13] .…”

“…Endoscopic treatment is possible by using esophageal luminal stents or by managing the esophageal wall defect with placement of clips but is reserved to selected cases and the first one is not superior comparing to primary sugical repair [13] . The endoscopic approach is preferred when there are no signs of sepsis and there is minimal contamination of the pleural and mediastinal spaces [14] .…”

“…Delayed diagnosis results in severe mediastinal infection, sepsis and death. BS management needs to be adapted to patient presentation, lesion extension, time from diagnosis and viability of esophageal wall [5] , [9] .It can imply a conservative, endoscopic or operative management [11] , [12] , [13] , [14] , [15] . Conditions needed for conservative management are: early diagnosis (<24 h), absence of symptoms or sepsis, contained cervical or thoracic perforation, no preexistent esophageal disease and a close surveillance by expert team [11] .…”