A 46-YR-OLD male with gastroesophageal reflux disease presented to the emergency department with acute onset of severe chest pain, abdominal pain, and dyspnea after an episode of intense coughing and vomiting. Chest radiograph demonstrated subcutaneous and mediastinal air (arrows), bilateral pneumothoraces (arrowheads), basilar consolidation, and pleural effusions (PE). Computerized tomography confirmed subcarinal mediastinal air (arrows) around the descending thoracic aorta (A) and thickened distal esophagus (E), with associated bilateral pneumothoraces (arrowheads), and pleural effusions. A diagnosis of spontaneous esophageal rupture, or Boerhaave’s syndrome, was made. The patient underwent a distal esophagectomy and cervical esophagostomy and experienced an uneventful postoperative course.
Boerhaave’s syndrome involves spontaneous perforation of the esophagus after a rapid intraesophageal pressure increase, such as occurs with severe vomiting and retching.1
It carries a high mortality. Gastroduodenal ulcers and alcoholism are associated with this syndrome.1
Subcutaneous emphysema and a left-sided pleural effusion are classically present.1
Chest computerized tomography confirms the diagnosis. Treatment typically involves immediate surgery. In addition to anticipation of hemodynamic disturbances due to inflammation, sepsis, fluid shifts, and blood loss, anesthetic management entails minimizing increases in esophageal and intraabdominal pressures that could result in gastric content extrusion from the ruptured esophagus.1–3
Although no studies exist examining nasogastric tube placement and Sellick’s maneuver, these measures are not clinically advised because it is best to avoid aggravation of esophageal injury and further mediastinal contamination.3
If possible, a rapid-acting nondepolarizing neuromuscular blocking agent such as rocuronium or administration of a defasciculating dose of nondepolarizing agent before succinylcholine is recommended to avoid succinylcholine-associated intragastric pressure increases.