Hospital Medicine

Esophageal Rupture (Borhaves)

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I. What every physician needs to know.

Spontaneous esophageal rupture is also known as Boerhaave's Syndrome, and occurs after forceful vomiting. The lower third of the esophagus, on the lateral left side, is anatomically the weakest area and is the location of the rupture in 90% of cases. Unlike a Mallory-Weiss tear, esophageal ruptures are full thickness tears of the esophagus.

Patients usually report forceful vomiting followed by severe chest pain and nausea. Although most papers describe the classic presentation of esophageal rupture as chest pain, and subcutaneous emphysema, patients rarely present with this triad. Additionally, patients have a wide variety of past medical histories and presentations. Thus, diagnosis and recognition of esophageal rupture is difficult and often missed. Esophageal rupture is a life threatening disease, with an estimated mortality rate of 20-40%. Patients usually suffer severe complications including mediastinitis, empyema, sepsis and eventually multi-organ failure.

II. Diagnostic Confirmation: Are you sure your patient has Esophageal Rupture?

The gold standard for diagnosis has typically been a contrast swallowing study showing leakage of contrast material from the esophagus. However, computed tomography (CT) Chest is also now considered to be diagnostic as PO contrast can be administered and seen leaking from the esophagus as well. Additionally, CT Chest is usually more readily available than a swallowing study.

A. History Part I: Pattern Recognition:

The typical patient presents with chest pain and nausea after a fit of forceful, uncoordinating vomiting. Depending on their delay in presentation, patients can also present unstable and in shock. Patient can present within a few hours of rupture or after a several day delay, accounting for much of the variability in presentation.

B. History Part 2: Prevalence:

Situations leading to increased emesis can have a greater chance to lead to esophageal rupture, such as alcohol abuse (one review showed 40% of patients had a history of alcoholism or heavy drinking) or bulimia.

C. History Part 3: Competing diagnoses that can mimic Esophageal Rupture.

Given the wide array of symptoms that esophageal rupture can present with, patients can often be misdiagnosed with other disease processes such as pancreatitis, myocardial infarction, acute pulmonary embolus, pericarditis, perforated ulcer and dissecting aneurysm.

D. Physical Examination Findings.

Patients may have severe chest pain and subcutaneous emphysema on the chest wall. Esophageal leakage can also lead to mediastinitis, pleural effusion (decreased breath sounds at base), and pneumothorax (decreased breath sounds with decreased fremitus). Depending on their clinical status, they may have signs and symptoms of sepsis.

E. What diagnostic tests should be performed?

The gold standard diagnostic tool thus far has been a contrast swallowng study showing leakage of contrast material from the esophagus. More recently, however, CT Chest is becoming a more readily available diagnostic option with likely equally as reliable results. CXR can also be done as an initial evaluation, however, it is often normal even in the presence of esophageal rupture. When it is abnormal, you may see evidence of a pleural effusion (usually left sided) or atelctasis and pneumothorax.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

There are no laboratory tests to diagnose esophageal rupture. However, lab studies are needed to help rule out other causes of the patients symptoms, such as cardiac enzymes for chest pain and concern for MI, pancreatic enzymes for epigastric pain and concern for pancreatitis. A CBC may demonstrate a leukoctosis which would not be diagnostic for esophageal rupture, but can be increased in patients with extensive infectious complications from rupture. It is important to note, however, that patients can present with completely normal lab values, or can present with abnormal tests consistent with sepsis.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

  1. CXR - a good initial evaluation tool, however, it is normal in post patients. When abnormal, you may see left sided effusion, atelectasis, pneumothorax or pneumomediastinum.

  2. Oral contrast swallowing study - you can see leakage of the contrast from the esophagus into the mediastinum or pleural space.

  3. CT Chest - may show full thickness tear of the esophagus with leakage of contrast into the mediastinum, pneumomediastinum, as well as the same lung pathology that can be seen on CXR.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

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III. Default Management.

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A. Immediate management.

Boerhaave's syndrome is rare and there is no concensus on appropriate treatment. There are, however, different treatment options that can be considered, and depend on the patient's presentation in terms of: delay of presentation, time to diagnosis, severity of rupture, subsequent comorbitidies from the rupture, patient's clinical condition and presence of underlying esophageal disease.

The first priority for management is stabilizing the patient if they are unstable and getting them to the appropriate next level of care such as the ICU. Patients usually need to have an NG tube placed to intermittent suction, broad spectrum antibiotics initiated, and parenteral nutrition initiated once they are stabilized and adequate access is obtained.

B. Physical Examination Tips to Guide Management.

Physical exam is important to assess for signs of severe comorbidities such as pneumomediastinum, pneumothorax, or severe sepsis as these would all require immediate management.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

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D. Long-term management.

Treatment plans should be developed in conjunction with the GI and surgery subspecialty services. Treatment can be conservative, with antibiotics with or without more aggressive therapy with primary surgical repair of the rupture or secondary isolation of the esophagus from the stomach to prevent leakage of additional gastric contents into the mediastinal space. It is important to note that if patients are treated conservatively and start to show signs of decline, they will likely need surgical repair. Older studies demonstrated higher mortality rates for patients treated conservatively or with delayed surgical repair, however, newer case reports describe more similar outcomes with conservative management when primary repair is not possible or delayed.

E. Common Pitfalls and Side-Effects of Management.

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IV. Management with Co-Morbidities.

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A. Renal Insufficiency.

No change in standard management.

B. Liver Insufficiency.

No change in standard management.

C. Systolic and Diastolic Heart Failure.

No change in standard management.

D. Coronary Artery Disease or Peripheral Vascular Disease.

No change in standard management.

E. Diabetes or other Endocrine issues.

No change in standard management.

F. Malignancy.

If esophageal rupture occurs at or near the site of an esophageal malignancy, the patient will likely need esophageal resection.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD).

No change in standard management.

I. Gastrointestinal or Nutrition Issues.

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J. Hematologic or Coagulation Issues.

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K. Dementia or Psychiatric Illness/Treatment.

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V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

Stable patients can rapidly become unstable at any point in their hospitalization. Therefore when transitioning care of the patient when you leave the hospital, it is important to give the on-call team a plan for what to expect and what to do if the patient decompensates as it will likely involve other services such as GI and surgery. As always, it is important to make sure that everyone is aware of the patient's code status and level of care wishes if they were to decompensate.

B. Anticipated Length of Stay.

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C. When is the Patient Ready for Discharge.

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D. Arranging for Clinic Follow-up.

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1. When should clinic follow up be arranged and with whom.

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2. What tests should be conducted prior to discharge to enable best clinic first visit.

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3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

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E. Placement Considerations.

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F. Prognosis and Patient Counseling.

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VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

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B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

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VII. What's the evidence?

Khan, AZ, Strauss, D, Mason, RC. "Boerhaave's Syndrome: Diagnosis and surgical management.". Surgeon.. 2007. pp. 39-44.

de Schipper, JP, Pull ter Gunne, AF, Oostvoge, HJ, van Laarhoven, CJ. "Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm.". Dig Surg.. vol. 26. 2009. pp. 1-6.

Teh, E, Edwards, J, Duffy, L, Beggs, D. "Boerhaave's syndrome: A review of management and outcome.". Interact Cardiovasc Thorac Surg.. vol. 6. 2007. pp. 640-3.

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