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Spontaneous Esophageal Rupture: Boerhaave's Syndrome

Singh, Harmeet MD; Warshawsky, Martin E. MD; Herman, Steven MD; Shanies, Harvey M. PhD, MD

Clinical Pulmonary Medicine: May 2003 - Volume 10 - Issue 3 - p 177-182
doi: 10.1097/01.cpm.0000059371.04504.4a
TOPICS IN PULMONARY MEDICINE

Spontaneous esophageal rupture (SER) is the most frequently fatal gastrointestinal perforation. Vomiting is the usual but not the sole etiology of SER. Rapid rises in esophageal pressure, discoordination of the vomiting reflex, and underlying esophageal disease contribute to its occurrence. The classic Meckler's triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases. The most common chest radiograph findings in SER are pleural effusion (91%) and pneumothorax (80%). The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema. Up to 12% of patients with SER may have a normal chest radiograph. Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases. If there is no extravasation of contrast but clinical suspicion remains high, the study should be repeated. The pleural effusion is characterized by a high amylase concentration and low pH. Pleural fluid pH below 6 is highly suggestive of SER. The appearance of food particles in pleural fluid is diagnostic of SER. Survival rate following early surgical intervention is 70%, and operative mortality is 10% to 30%. A delay of surgical treatment greater than 24 hours is associated with a 64% mortality. Hence, early recognition and operation are critical. The correct diagnosis of SER is usually not made within the first 12 hours after occurrence. A high index of suspicion is crucial since in most instances a chest radiograph and esophagogram can provide the diagnosis. The presence of shock, severe debilitation, and a moribund state are urgent indications rather than contraindications to surgical treatment.

Spontaneous esophageal rupture is a condition with a 70% surgical survival rate after early surgery. A preoperative delay of more than 24 hours results in a significant rise in mortality. The diagnosis is often delayed or missed because of the variable presentation and the low incidence of the condition. If the clinical suspicion of spontaneous esophageal rupture is great, multiple testing modalities should be employed until the diagnosis of SER is reasonably excluded or confirmed.

From the Mount Sinai School of Medicine, Elmhurst, NY, USA

Address correspondence to: Martin E. Warshawsky, MD, Division of Pulmonary and Critical Care Medicine, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373.

© 2003 Lippincott Williams & Wilkins, Inc.