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Boerhaave’s SyndromeBoerhaave’s Syndrome
• "Spontaneous" esophageal rupture was described by Boerhaave in 1724.– Dutch admiral Baron John von
Wassenauer overindulged on roast duck and wine, subsequently vomited/died
– Autopsy revealed gastric contents in pleural space
– at the time surgery was considered “a fools venture”
Herman Boerhaave1668-1738
Herman Boerhaave1668-1738
• Dutch physician, botanist, chemist, medical educator, philosopher– self taught medicine– attended dissections but not lectures– married daughter of a rich merchant– did lectures for $– treated rich and famous– insisted on autopsies– bedside teaching– did consults by mail– Never had a bad hair day
Boerhaave’s SyndromeBoerhaave’s Syndrome
• Classic triad– vomiting, – excruciating chest pain– subcutaneous emphysema
CXRCXR
• Left pleural effusion/ left hydropneumothorax in 12 to 24 hours.
• Pulmonary infiltrates
• SubQ air
• Widened mediastinum
Boerhaave’s SyndromeBoerhaave’s Syndrome
• Anatomy– perf of esophagus -> mediastinum
– negative pressure promotes soilage
– 90% tears along the left, posterolateral wall of the distal esophagus
– role of esoph. disease is ?
• Etiology– retching against a closed glottis
• also laughing, childbirth, sz, trauma, heavy lifting
• most common cause upper endoscopy (~60%)
CausesCauses
• Endoscopy (~60%)• Dilations• NG tubes• Neck/abd Surgery• Post emetic• Infection
• Blunt trauma• Caustics• Foreign body• Esoph disease
Boerhaave’s Syndrome Clinical features -may be delayed!Boerhaave’s Syndrome Clinical features -may be delayed!
• Pain, (pleuritic, back, chest, abd)
• Dyspnea• Subq Air/
mediastinal air• Hamman’s
crunch (systolic)
• Vomiting• Dysphagia • Change in voice• Sepsis
Boerhaave’s SyndromeBoerhaave’s Syndrome
• Treatment– ABCs– NPO– Antibiotics/fluids– Consultation
• Outcome– survival 65-90%– poor survival w/ delayed dx >48hrs
Boerhaave’s SyndromeBoerhaave’s Syndrome• Diagnosis
– often difficult– 1/3 presentations are atypical– Differential dx
• Spont. Mediastinum• Thoracic Aortic Aneurysm• PE• PUD• Pancreatitis• Mesentaric ischemia