Summary about Disease
Boerhaave syndrome is a spontaneous esophageal rupture that occurs due to a sudden increase in pressure within the esophagus, often during forceful vomiting. It is a life-threatening condition because it leads to leakage of esophageal contents into the mediastinum (the space between the lungs), causing inflammation, infection (mediastinitis), and potentially sepsis.
Symptoms
Sudden, severe chest pain, often described as tearing or ripping.
Upper abdominal pain.
Pain in the back, neck, or shoulder.
Dysphagia (difficulty swallowing).
Odynophagia (painful swallowing).
Vomiting, often followed by blood.
Shortness of breath.
Signs of shock: rapid heart rate, low blood pressure, sweating.
Subcutaneous emphysema (air under the skin, felt as crackling).
Hamman's sign (a crunching sound heard over the heart during systole, indicating air in the mediastinum).
Causes
Forceful vomiting (most common).
Retching.
Straining during bowel movements.
Difficult labor.
Heavy lifting.
Seizures.
Blunt trauma to the chest or abdomen.
Esophageal instrumentation (rare).
Underlying esophageal disease, such as esophagitis or esophageal ulcers, may increase risk.
Medicine Used
Antibiotics: Broad-spectrum antibiotics are essential to combat infection and prevent sepsis. Examples include carbapenems (e.g., meropenem, imipenem), piperacillin/tazobactam, or combinations of antibiotics depending on the suspected organisms.
Pain management: Strong analgesics, often opioids (e.g., morphine, fentanyl), are required to control the severe pain.
Antiemetics: To reduce nausea and vomiting.
Proton pump inhibitors (PPIs): To reduce stomach acid production and prevent further esophageal irritation.
Nutritional Support: Parenteral nutrition (IV feeding) is often necessary to bypass the esophagus and provide nutrition while it heals.
Antifungal medications: May be needed if fungal infection is suspected.
Is Communicable
No, Boerhaave syndrome is not communicable. It is a spontaneous rupture caused by physical forces, not an infectious agent.
Precautions
Since Boerhaave syndrome is usually a spontaneous event, true preventative precautions are limited. However, the following may reduce risk:
Avoid overeating or drinking to excess.
Seek prompt treatment for esophageal disorders (esophagitis, ulcers).
Manage conditions that cause forceful vomiting.
Avoid activities that significantly increase intra-abdominal or intrathoracic pressure (e.g., extremely heavy lifting without proper technique).
How long does an outbreak last?
Boerhaave syndrome isn't an "outbreak" but a single, acute event. The duration of illness depends entirely on how quickly it's diagnosed and treated. Without prompt treatment, it is rapidly fatal. With surgical repair, intensive care, and antibiotics, recovery can take several weeks to months, depending on the extent of the damage and any complications.
How is it diagnosed?
Clinical presentation: The sudden onset of severe chest pain, often after vomiting, is highly suggestive.
Chest X-ray: May show mediastinal widening, pleural effusion, pneumothorax, or subcutaneous emphysema.
Computed tomography (CT) scan of the chest: Provides more detailed imaging of the esophagus, mediastinum, and surrounding structures, revealing the rupture site, mediastinitis, and fluid collections.
Esophagography (Barium Swallow/Gastrografin Swallow): Involves swallowing a contrast agent (barium or Gastrografin) and taking X-rays to visualize the esophagus. Gastrografin is often preferred initially as it is less irritating to the mediastinum if it leaks. The contrast can be seen leaking through the esophageal tear.
Esophagoscopy: Endoscopic examination of the esophagus to visualize the rupture site directly. This is often delayed until after initial stabilization and imaging to minimize the risk of further complications.
Timeline of Symptoms
The onset of symptoms is typically acute and sudden.
Initial event: Forceful vomiting, retching, or other triggering event.
Immediate: Sudden, severe, tearing chest pain.
Within hours:
Pain worsens.
Dysphagia/odynophagia.
Shortness of breath.
Signs of shock (if severe leakage and infection develop quickly).
Days (without treatment):
Sepsis.
Multi-organ failure.
Death.
Important Considerations
Mortality is high without rapid diagnosis and treatment. Time is critical.
Treatment usually involves surgery to repair the esophageal tear and drain the mediastinum. However, non-operative management may be considered in very select cases (e.g., contained perforation, early diagnosis, minimal symptoms).
Complications are common, including mediastinitis, sepsis, empyema (pus in the pleural space), ARDS (acute respiratory distress syndrome), and fistula formation.
Nutritional support is crucial during the healing process.
Long-term complications can include esophageal strictures (narrowing) and motility disorders.