Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial

Mediastinitis and septic shock complicating spontaneous esophageal rupture "Boerhaave's syndrome": a case report

Boerhaave's syndrome, also known as spontaneous esophageal rupture, is a rare but life-threatening condition characterized by a tear in the esophagus. It is most commonly caused by a sudden increase in intraesophageal pressure, often due to severe vomiting or retching.Early diagnosis of Boerhaave's syndrome is crucial for improving patient outcomes. The classic triad of symptoms includes severe chest pain, vomiting, and subcutaneous emphysema (air under the skin). However, not all patients present with this triad, and the diagnosis can be challenging, especially in patients without the typical symptoms.In this case report, we present the clinical details of a 52-year-old male patient who presented to the emergency department (ED) with severe abdominal pain and vomiting for several days. The patient had a history of chronic alcohol abuse and a recent episode of vigorous vomiting.

Boerhaave's Syndrome: An Unusual Geriatric Presentation

Boerhaave's syndrome (BS) is a non-iatrogenic spontaneous esophageal perforation that, if not appropriately recognized and managed, can cause localized infections such as mediastinitis, pneumonia, and empyema, as well as systemic infections with significant morbidity and mortality rates. An autonomous 83-year-old male presented to the emergency department with a three-day history of behavioral changes. Three days earlier, the patient had a self-limited episode of cough, nonspecific thoracalgia, palpitations, prostration, and pallor. On physical examination, he was alert but had temporal disorientation, hypoxemia, and pulmonary auscultation with abolished breath sounds in the middle third of the left chest. Laboratory tests showed hypoxemia, elevated C-reactive protein (28.2 mg/dL), and D-dimer (3.28 µg/mL). A chest X-ray revealed periaortic small bubbles, left atelectasis, and left pleural effusion. Computed tomographic angiography of the chest showed infra-carinal esophageal rupture, small bubbles of the anterior pneumomediastinum, and a loculated left pleural empyema. Mediastinitis and empyema due to BS were assumed. He underwent left thoracic drainage, broad-spectrum antibiotics, and the placement of a surgical esophageal prosthesis. He was discharged after 48 days. The condition known as BS is frequently misdiagnosed, mostly as a result of the lack of a preexisting pathological background and the wide array of potential symptoms that may manifest. The diagnosis in this particular case was rendered particularly complex due to the combination of an unusual presentation and a delayed seeking of medical attention. Against all expectations, our patient was successfully treated.

Acute Upper Airway Obstruction Due to Massive Cervical Subcutaneous Emphysema: A Case Report

With upper airway obstruction being an emergency, a high index of suspicion and proper and timely treatment planning are crucial to the patient's life. Spontaneous esophageal perforation, also known as Boerhaave syndrome, has been observed to cause subcutaneous emphysema; however, airway compromise secondary to subcutaneous emphysema is extremely rare when there is no associated broncho-tracheal injury. Here, we present a case of esophageal perforation complicated with cervical emphysema that led to acute airway obstruction requiring invasive ventilation.

Catastrophic right-sided Candida empyema from spontaneous esophageal perforation

Right-sided empyema secondary to esophageal rupture are rare but reported in the medical literature. We describe an atypical CASE of right-sided empyema with Candida Tropicalis, Candida Glabrata, and Staphylococcus lugdenensis leading to a diagnosis of spontaneous esophageal rupture. We concluded that pleural effusion with fungal and multi-organism growth should immediately raise suspicion for underlying missed esophageal perforation. Prompt diagnosis of esophageal perforation can prevent fatal complications like pleuritis, pneumothorax, hydrothorax, pneumomediastinum, mediastinitis, acute respiratory distress syndrome, and septic shock.

The addition of flexible endoscopic suturing to stenting for the management of transmural esophageal wall defects: a single tertiary center experience

BACKGROUND AND AIMS

Endoscopic stenting is the standard of care for full thickness esophageal wall defects. The aim of this study is to evaluate outcomes of endoscopic closure of esophageal defects using stenting, with or without endoscopic suturing.

METHODS

This is a single-center retrospective study of patients with esophageal wall defects who underwent endoscopic interventions. Outcomes of stenting with or without endoscopic suturing of the defect were assessed. Univariate and multivariate logistic regression models were used to examine factors associated with successful defect closure.

RESULTS

One hundred and fourteen patients with esophageal wall defects underwent 254 endoscopies with an overall complete closure rate of 75.8%. Twenty-three (20.2%) patients underwent primary closure using endoscopic suturing and subsequent esophageal stenting, while 91 (79.8%) underwent esophageal stenting only. The dual modality group (versus the stent-only group) had similar defect closure rates (84.2 vs. 73.8%, p = 0.55) and time to stent migration (37 vs. 12.5 days, p = 0.07), but was associated with longer procedure times (60 vs. 36 min, p < 0.01) and fewer additional endoscopic procedures (13.6 vs. 43.2%, p = 0.01). Stent suturing significantly decreased migration (35.5 vs. 58.5%, p = 0.04), was associated with fewer additional endoscopies (15.4 vs. 50%, p < 0.01) and reduced need for additional stents (7.7 vs. 34.3%, p < 0.01). On multivariate analysis, chronic defects (> four weeks old) were 81% less likely to close compared to acute (≤ 4 weeks) defects (OR 0.19, CI 0.04-0.77, p = 0.02), and large diameter stents (23 mm) were associated with higher odds of defect closure (OR 3.36, CI 1.02-11.4, p = 0.04).

CONCLUSION

Endoscopic treatment of esophageal wall defects is safe, effective, and more likely to be successful in acute defects using larger caliber stents. Stent suturing reduces migration, need for additional endoscopic procedures, and stent exchanges. Further comparative studies with larger cohorts are needed to validate our results.

Tension hydropneumothorax as the initial presentation of Boerhaave syndrome

Boerhaave syndrome, a rare yet frequently fatal diagnosis, is characterized by the spontaneous transmural rupture of the esophagus. The classic presentation of Boerhaave syndrome is characterized by Mackler's triad, consisting of chest pain, vomiting, and subcutaneous emphysema. However, Boerhaave syndrome rarely presents with all the features of Mackler's triad; instead, the common presentation of Boerhaave syndrome includes chest or epigastric pain, severe retching and vomiting, dyspnea, and shock. These symptoms are typically misdiagnosed as cardiogenic in origin. Due to its atypical presentation, rarity, and mimicry of emergent conditions, diagnosis of Boerhaave syndrome is often delayed, resulting in a high mortality rate at the time of diagnosis and with a subsequent exponential increase in mortality if treatment is delayed by greater than 48 hours. Here, we report two atypical presentations of Boerhaave syndrome presenting as tension hydropneumothorax and review ten previously reported cases of Boerhaave syndrome presenting as tension hydropneumothorax. This review serves to raise clinician awareness about the expansive and elusive ways by which esophageal perforation may present, and thereby facilitate timely and potentially life-saving diagnosis.

Two-tube method for treatment of spontaneous esophageal rupture and concomitant mediastinal infection

Objective

Spontaneous esophageal rupture (SER) is a rare but life-threatening condition with high mortality. The prognosis of patients with SER treated with surgical intervention or the traditional “three-tube” method is controversial. Thus, the aim of this study was to evaluate the clinical efficacy, feasibility, and safety of a new “two-tube” method involving a trans-fistula drainage tube and a three-lumen jejunal feeding tube for the treatment of SER without concomitant pleural rupture.

Methods

From January 2007 to June 2016, patients with SER and managed with the “two-tube” method or other methods were retrospectively analyzed. Data collected included initial presentation, procedure time, duration of treatment, numbers of patients with eventual healing of leaks, and complications.

Results

The average procedure time for the “two-tube” method was 22.1 ± 5.5 minutes. In comparison with the control method, the “two-tube” method had a similar diagnosis time (3.6 ± 1.4 vs. 3.4 ± 1.4 days) but a significantly higher successful closure rate (94.4% vs. 63.6%) and shorter treatment time (38.2 ± 5.6 vs. 53.6 ± 16.9 days). No complications associated with performance of the “two-tube” method occurred.

Conclusion

The “two-tube” method is an effective and safe approach for patients with SER.

Cardiac arrest due to a missed diagnosis of Boerhaave's syndrome

A 91-year-old presented with a rare cause of cardiac arrest. He was initially admitted with severe back pain following vomiting and diagnosed with probable aspiration pneumonia. On day 3 of admission, he was discovered in cardiac arrest and cardiopulmonary resuscitation was started. On intubation, a left-sided pneumothorax and subcutaneous emphysema were noted. Needle decompression showed gastric fluid leaking from the cannula. The patient regained a cardiac output, and a subsequent CT scan confirmed a large pneumomediastinum with air tracking to the neck and chest, and bilateral pneumothoraces. A diagnosis of Boerhaave's syndrome was made. The patient was transferred to the intensive care unit but did not survive. This case demonstrates the importance of looking for and treating the rarer reversible causes of cardiac arrest, and of maintaining a high index of suspicion for Boerhaave's syndrome. Despite its rarity, Boerhaave's syndrome is often misdiagnosed on initial presentation, leading to delayed treatment and poor outcomes.

Right-sided hydropneumothorax as a presenting symptom of Boerhaave's syndrome (spontaneous esophageal rupture)

Boerhaave's syndrome, or spontaneous esophageal rupture, is a rare condition that classically presents with Mackler's triad of vomiting, subcutaneous emphysema, and severe sudden onset of chest pain and requires immediate medical attention. Approximately 90% of the perforations occur at the left lateral aspect of the distal esophagus, causing a left-sided pleural effusion. Less than 10% of patients have bilateral effusions, and few patients have a right-sided pleural effusion only. We present the case of a 59-year-old man with spontaneous esophageal rupture. His clinical presentation is of interest since he had no inciting event for spontaneous esophageal rupture and had a delayed presentation with a right-sided hydropneumothorax.