Boerhaave Syndrome – Causes, Symptoms and Treatment

Boerhaave syndrome

essentially refers to the ruptures in the esophageal wall due to excessive vomiting. 85-90% of esophageal ruptures are caused by iatrogenic perforations. Iatrogenic perforations refer to the ruptures caused involuntarily by surgical instruments like a nasogastric feeding tube, an endoscope or during paraesophageal surgery. The discussed syndrome refers to the 10% of cases which are caused only by vomiting or intense retching and not by iatrogenic perforations.

Unlike in Mallory Weiss syndrome, where tears in the esophageal wall can be dealt with, the discussed condition deals with perforations as big as holes. The most common site of the occurrence of this syndrome is the left posterolateral wall in the lower third of the esophagus. It is the weakest point in the esophagus. This condition is two times more common in men. The tears or cuts are mostly vertical and can measure between 1 and 4 cms.


Causes of Boerhaave syndrome

  • Spontaneous perforation of the esophagus is caused by an increase in the intraesophageal pressure combined with a reduction in the intrathoracic pressure ( contraction of the diaphragm). It causes a massive strain in the esophagus resulting in the perforations.
  • Other reasons causing strained vomiting could include the ingestion of caustic abrasives, reflux esophagitis, pill esophagitis, Barret’s ulcer, infectious ulcers in immune compromised patients.
  • Forceful vomiting in eating disorders like bulimia nervosa or forceful cough caused by choking on food.
  • Treating esophageal strictures with dilation can also cause the tears.
  • Overindulgence in food and alcohol is known to cause it.

Symptoms of the condition

  • It is said to cause the “Mackler’s Triad”. It includes vomiting, chest pain and subcutaneous emphysema (lung disease causing shortness of breath). It is found in almost 14% of the patients of this condition.

Other symptoms would be as follows:

  • Tight chestedness.
  • Upper abdominal pain. Pain can radiate towards left shoulder and can confuse one with the symptoms of myocardial infarction or heart attack.
  • Odynophagis or difficulty in swallowing food.
  • Tachypnea or rapid breathing to the extent of greater than 20 breaths per minute.
  • Dyspnea or shortness of breath is seen especially in infants.
  • Cyanosis or the blue/purple discoloration of the skin especially seen in infants with the condition.
  • One of the complications of the condition is the occurence of mediastinitis ( inflammation of the area between the lungs) and associated sepsis ( widescale spread of infection in the blood stream).

Treatment of Boerhaave syndrome

  • Antibiotic therapy to prevent medistinitis and sepsis.
  • Surgical intervention to repair the hole or perforation in the esophageal wall.
  • If there is dehydration, restoring hydration becomes necessary by administering an intra venous drip as oral rehydration would be painful.
  • The mortality from untreated Boerhaave syndrome is 100%. Even with surgical intervention within 24 hours of detection of the condition the mortality rate is about 25%.

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