Boerhaave's syndrome

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					                                        R A D I O L O G I C A L                                              C A S E

Boerhaave’s syndrome
Jeffrey M. Pollock, MD, Jeffrey C. Brandon MD, Margaret H. Mowry, MD, and Steven K. Teplick, MD

   A 51-year-old woman presented to
our emergency room with acute onset
of left shoulder and epigastric pain. The
pain followed an episode of choking
and retching during a dinner at a steak-
house. On physical exam her abdomen
was tender to palpation most notably in
the upper quadrants where she had
guarding and rebound tenderness. Lab-
oratory values were unremarkable.

IMAGING FINDINGS                             FIGURE 1. Upright PA view of the chest show-      FIGURE 2. CT of the Chest with contrast
                                             ing a double gastric bubble consistent with       using lung windows shows mediastinal air
   A chest X-ray (Figure 1) showed free
                                             free intraperitoneal air. There was no evidence   tracking between the esophagus and the
air adjacent to the stomach bubble in the    of pneumomediastinum or pleural effusion.         aorta.
left upper quadrant. A computed tomog-
raphy (CT) scan (Figures 2 and 3) of the     thoracotomy. A piece of brown tissue              autopsy showed a tear in the distal
chest, abdomen and pelvis, using intra-      was removed from the mediastinum                  esophagus, emphysema and food in the
venous and oral contrast, showed medi-       and sent to pathology where it was                mediastinum.1
astinal air adjacent to the descending       found to be skeletal muscle consistent               Esophageal rupture is likely sec-
aorta. The CT scan also showed free          with the piece of steak the patient               ondary to a rapid rise in the intralumi-
intraperitoneal air and a soft-tissue den-   reported ingesting prior to the episode           nal pressure of the distal esophagus
sity adjacent to the distal esophagus        of vomiting. The patient had an                   during emesis.2
(Figure 4). No contrast extravasation        uncomplicated hospital course. Upper                 The syndrome can be a challenge for
was seen on CT. Subsequently, barium         GI examination 1 week post esoph-                 clinicians because the clinical presen-
swallow showed an area of contrast           ageal repair showed no evidence of                tation rarely has the classic presenta-
extravasation from the distal esophagus      extravasation or stricture formation.             tion of retrosternal chest pain
2.0 cm proximal to the gastroe-              The patient was seen for routine                  following an episode of emesis with
sophageal junction (Figure 5).               screening mammography 2 years later               associated emphysema. Patients may
                                             and was asymptomatic.                             have symptoms that can mimic
DIAGNOSIS                                       Boerhaave’s syndrome was origi-                myocardial infarction, sepsis, pancre-
   Boerhaave’s syndrome                      nally described by Hermann Boer-                  atitis or aortic dissection. Additionally,
                                             haave in 1724. The first report was the           the patients may present with hypoten-
DISCUSSION                                   case of Bar
Description: The most specific findings on CT include air around the distal esophagus and aorta, pleural effusions, esophageal wall thickening and pulmonary infiltrates.4 A fluoroscopic esophagram performed with water soluble contrast is the diagnostic procedure of choice in patients with suspected perforation of the esophagus. Dilute barium can be used if the water soluble contrast is not diagnostic.5 Findings on esophagram that are indicative of perforation include direct visualization of the submucosal tear or extravasation of contrast. 4 While visualization of the fistula or the actual tear is a definitive finding, there has been a =10% false-negative rate reported with esophagography.6 Helical CT esophagography using oral solution composed of 10% IV iodinated contrast material, effervescent granules and water has shown promising results for demonstrating esophageal extravasation.7 The treatment of choice consists of emergent primary surgical repair of the esophageal tear and removal of debris from the mediastinum.
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