Recheck chest CT was performed after the operation. 17 days later, emphysema and subcutaneous emphysema disappeared (Fig. 5). Laboratory analysis revealed serum RBC 3.98cell/L; Hgb 113 g/L; HCT 33.6% 20 days later after the operation. Recovery was complicated by renal failure, leading to death 61 days after admission.
Spontaneous esophageal rupture, also known as Boerhaave syndrome is a rare but severe gastrointestinal disease, its early symptoms are similar to chest and abdomen emergencies, diagnosis and treatment are often delayed, in some cases will lead to adverse results. The rupture of the esophagus most commonly results from a full-thickness transmural rupture of the normal esophageal wall due to a sudden increase in intraesophageal pressure caused by nausea or vomiting. Spontaneous esophageal rupture has been reported, including patients with gastrointestinal stenosis, Barrett's esophagus, vomiting during pre-treatment for an endoscopic examination, and vomiting after general anesthesia. In most cases of spontaneous esophageal rupture, the tearing along the fiber is mostly longitudinal slit, generally 0.6–8.9 cm, can also reach 10–12 cm, 90% occurs in the left chest, mostly in the lower left of the esophagus, and also into the right side and the abdominal cavity. Most of the clinical manifestations are atypical. Early manifestations include sudden chest pain or upper abdominal pain, radiation to the shoulders and back, accompanied by difficulty in breathing, chest tightness, fever and other symptoms. This characteristic history is the key to diagnosis of spontaneous rupture of esophagus and should be regarded as the first possible diagnosis. Chest radiographs and CT are important in the diagnosis of subcutaneous emphysema, mediastinal emphysema and pleural effusion.
Gastroscopy is a remarkably safe and effective method of diagnosing gastrointestinal tract disease, widely used in clinical setup. Most of the complications can be avoided by complying with general gastroscopy rules. Due to its rare incidence, most spontaneous perforation of the esophagus during diagnostic gastroscopy reports in the medical literature are case reports. Only 2 similar cases of this article reported previously. The 2 patients were both elderly, one was a 1.5 cm tear was confirmed in the lower esophagus posteriorly, other was a 5 cm tear in the left lateral wall of the esophagus. Our patient was a 6 cm tear in the lower esophagus posteriorly. Since the establishment of our hospital, this is the first patient of spontaneous esophageal rupture induced by gastroscopy, even domestic. This patient mainly due to the following reasons: Nausea and vomiting were evident during gastroscopy, leading to a significant increase in hypoesophageal pressure. In addition, the patient had poor nutritional status, thin lower esophagus muscle layer, leading to spontaneous esophageal rupture.
Esophageal rupture is the most serious and rapidly lethal perforation of the gastrointestinal tract, once diagnosed, immediate treatment was needed. Delayed diagnosis and treatment can rapidly lead to severe life-threatening infections such as empyema and mediastinitis, and multiple organ failure. The treatment strives to be carried out within 24 h of diagnosis, and the mortality rate of patients exceeding 24 h is extremely high. The principle of treatment is to remove the source of pollution, close the breach, restore the integrity of the esophagus, fully drain, control the infection, strengthen the nutritional support, improve the body and promote wound healing. Traditional surgical treatment is the primary suture repair of the rupture and adequate drainage time of the mediastinum and chest. However, for this patient, the doctor tried endoscopic suturing techniques under endotracheal intubation, performed titanium clip clamping, and over the scope clip (OTSC) sealing. The procedure was smooth and the patient recovered well after operation. This endoscopic repair is less invasive and infective, and is very useful to patients.
In short, spontaneous esophageal rupture is an emergency and requires early diagnosis if death or serious long-term disease is to be avoided. A patient with spontaneous esophageal rupture was encountered during gastrointestinal endoscopy, and the disease was diagnosed by CT and endoscopically treated at an early stage of rupture. and postoperative recovery was satisfactory. For patients with severe malnutrition after gastric cancer surgery, there is a risk of spontaneous esophageal rupture during gastroscopy. Therefore, it is important to recognize this emergency so that appropriate treatment can be tried quickly to increase good results.
Conceptualization: Bin Ye.
Data curation: Feiyun He, Mugen Dai, Jiwang Zhou, Jiansheng He.
Formal analysis: Bin Ye.
Funding acquisition: Bin Ye.
Investigation: Feiyun He.
Methodology: Mugen Dai.
Project administration: Bin Ye.
Resources: Bin Ye, Jiwang Zhou, Jiansheng He.
Supervision: Jiansheng He.
Validation: Jiansheng He.
Writing – original draft: Feiyun He, Mugen Dai, Bin Ye.
Writing – review and editing: Feiyun He, Mugen Dai, Jiwang Zhou, Jiansheng He, Bin Ye.
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
gastroscopy; spontaneous esophageal rupture; Treament