• Clinical science

Boerhaave syndrome (Spontaneous esophageal rupture)

Summary

Boerhaave syndrome is the transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure. The condition is associated with recent excessive consumption of alcohol or food, repeated episodes of vomiting, and other causes of elevated intrathoracic pressure (e.g., childbirth, seizure, prolonged coughing). The classic complaint is severe retrosternal pain, which is due to the development of mediastinal emphysema after massive emesis. However, a third of patients with Boerhaave syndrome present atypically. Diagnosis is confirmed via chest x-ray, esophagram and/or CT. Surgical repair of the esophageal rupture is often essential, although conservative treatment alone may be considered in select cases (e.g., if the perforation is very small and the patients is stable).

Epidemiology

  • Age range: 50–70 years (but may present in any age group)
  • Sex: > (3:1)

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Associations
    • Excessive intake of alcohol or food in the recent past
    • Repeated episodes of vomiting
    • Childbirth
    • Seizures
    • Prolonged coughing
    • Weightlifting

Pathophysiology

  • Severe vomiting/increased intrathoracic pressure → rupture of all layers of the esophageal wall
  • In > 90% of cases, the rupture occurs in the distal third of the esophagus on the left dorsolateral wall surface.
  • Affected individuals typically do not have preexisting esophageal abnormalities.

Clinical features

Always ask about vomiting if a patient presents with thoracic pain! Approximately one‑third of patients present with atypical symptoms!

Diagnostics

If Boerhaave syndrome is suspected, a chest x-ray is first conducted. If inconclusive, an esophagram and/or CT scan is conducted to confirm the diagnosis

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Conservative treatment

  • Indications
    • Small, contained perforation, demonstrated by:
    • The perforation site is benign, outside of the abdomen, and distal to an obstruction
    • Stable medical condition without evidence of sepsis
    • Contrast studies can be performed at any time of day
    • A skilled thoracic surgeon must always be available
  • Approach

Surgical treatment

  • Indications
    • Clinical deterioration during conservative management
    • Patients who do not fulfill the criteria for conservative management
  • Approach
    • Surgical repair and closure of the ruptured esophageal segment
    • Last resort: esophagectomy

Complications

Mediastinitis

Others

We list the most important complications. The selection is not exhaustive.

History

Boerhaave, a Dutch physician in the 18th century, described this illness after a friend vomited and collapsed to his death following an extravagant meal they had eaten together. The autopsy, performed by Boerhaave, demonstrated esophageal rupture as the cause of death.