Thursday, June 12, 2014

When to Consider Boerhaave's Syndrome

Mary, at age 77, fell and was admitted to the hospital with a hip fracture and had surgery the following day.  Post-operatively she received narcotics for moderate pain.  Unfortunately she had vomiting and retching, then developed severe abdominal pain.  She had a history of a prior appendectomy, prior gall bladder removal, moderate COPD, and mild heart failure.

Accompanying the pain, her blood pressure fell, she became short of breath, and her oxygen levels fell.  This rapidly progressed.  Cultures were taken for infection, a chest X-Ray done, and antibiotics initiated.  Her kidneys began to malfunction and early signs of shock were present.

Her doctors thought of aspiration pneumonia, esophagitis, a dissecting aneurysm, heart attack, pneumonia, and pulmonary embolism - but were on the wrong track.  The X-Ray should have helped but was interpreted as not showing free air around the lungs or in the soft tissues.  A subsequent CT scan however, did show an abnormal collection of air in these areas.

Finally after 18 hours of going down the wrong path, a diagnosis of a ruptured esophagus was considered.  This was confirmed by putting some contrast dye down the esophagus showing it to leak into the surrounding tissues.  Also, an enzyme only present in saliva was present in the fluid from around the lung.

She was taken to surgery for repair 24 hours after presenting with pain, at a time when the mortality begins to approach 50 - 75%.  Unfortunately she continued to deteriorate and ultimately was placed on comfort care prior to dying.

Comment:  Herman Boerhaave was a brilliant Dutch physician, botanist, and humanist who, in 1724, described a corpulent patient's proclivity toward self-inducted vomiting in allow him to indulge in further overeating.  At autopsy his patient, Baron Jan Van Wassenaer, had olive oil and roast duck flesh outside an esophageal tear.  The condition known as Boerhaave's Syndrome is relatively rare but one of those bits of knowledge that needs to be in the thinking of surgeons and critical care physicians.  Unfortunately a delay in diagnosis of 24 hours leads to a very high mortality.  Samuel Johnson has written an interesting biography of Boerhaave.

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