EMed

Boerhaave's (oesophageal #)

Background

  • "Spontaneous" oesophageal rupture with vomiting
  • Mortality 25%(early Mx) - 90% (late Dx)
  • Left posterolateral oesophagus (lower ⅓)
  • M:F = 2:1, middle age and elderly

Clinical

Symptoms

  • Vomiting then epigastric pain (→back or shoulder)
  • Haematemesis rare
  • SOB and pleuritic left pain later

Signs

  • Mackler triad in ½
    • Vomiting, lower chest pain, subcut. emphysema
  • Clinically unwell (shocked) and in pain
  • ↑RR, hoarseness (recurrent laryngeal N)
  • Epigastric tenderness
  • Neck vein engorgement (or ↓ if shocked)
  • Hamman's crunch

Differential Dx

Investigations

  • ECG (? ACS / NSTEMI), TnI
  • Baseline labs. incl. VBG
  • LFTs & amylase(? alcohol)
  • Erect CXR (unilat. pleural effusion, pneumomediastimun, surgical emphysema)
  • CT thorax
  • Contrast swallow

Management

  • Analgesia, IV fluids, IV antibiotics ±NGT
  • Early surgical referral:
    • Conservative Mx (no contrast leak)
    • ± tube thoracostomy
    • Oespohageal repair (particularly if Dx early)

References

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 13/12/21.