The Esophagus is a muscular tube measuring about 25 cm connecting your throat with the stomach. This tube passes through the neck, reaching till the diaphragm and upper portion of the stomach. The muscular walls of esophagus would contract when you eat anything and pushes the food down. There would be continuous secretion of mucus by the glands to keep the esophagus moist.
The wall of the esophagus can get ruptured spontaneously due to several reasons. It can develop holes and tear due to application of force from medical instruments during surgery on this region or due to endoscopy procedure. In rare cases rupture of esophagus can occur due to severe vomiting. Due to sudden increase in the pressure or strain due to continued vomiting can cause holes or small tear in the wall of the esophagus. In some cases perforation can occur due to swallowing of acid or other chemicals or due to infectious ulcers in that area. This phenomenon of tearing of esophageal wall and rupturing is known as Boerhaave syndrome.
About 90% of esophageal rupture occurs during surgery or post-surgical period. Less than 10% may develop due to other reasons. The condition of esophageal rupture is very serious and needs immediate treatment. Tearing of wall of esophagus can occur in the posterior or lateral area and in rare cases it can become fatal. Since this condition was first reported by Herman Boerhaave of 18th century it is named after him. Boerhaave syndrome is difficult to diagnose since there would be no other symptoms. Early diagnosis and appropriate treatment or surgery is absolutely necessary to prevent death and life threatening consequences. This condition may lead to perforation in the gastro-intestinal tract which can become fatal.
Symptoms :
Boerhaave syndrome can cause intense pain in the chest or upper abdominal region along with severe vomiting. Depending on the causes the symptoms may vary. The symptoms of tachypnea (abnormally rapid breathing) or dyspnea (difficulty in breathing) or Sepsis (blood poisoning) or shock may follow perforation of esophagus. The area of pain differs considerably with the cause of injury and its intensity.
People with cervical esophageal rupture can develop intense pain in their neck and chest region. If the rupture develops in the middle portion of the esophagus the person can develop pain in the lower abdomen. This can be accompanied by Pleural Effusion (accumulation of fluid in the space between the lungs and chest).
In addition Boerhaave syndrome can also cause symptoms like hoarseness in voice, peripheral Cyanosis and distention of cervical vein. Within few hours, the person may develop high fever, infection, and hemodynamic instability. The person may develop obtundation (reduced level of alertness and mental instability) shortly.
Causes :
Boerhaave syndrome can develop due to internal and external factors. Surgical procedure on esophagus can cause tear and perforation in the area. Internal factors like severe vomiting, injury caused due to intraluminal pressure and ingestion of poisonous chemicals can tear the walls of esophagus. Tear occurs in the weakest point of the esophagus mostly in the left lower region. High consumption of alcohol can also cause perforation.
Diagnosis :
The symptoms of Boerhaave syndrome like excruciating pain in the chest can often be misdiagnosed for myocardial infarction or lung Abscess also. It is difficult to identify esophageal rupture through physical findings alone. CT scan and radiography of the esophagus are done if the doctor suspects rupture of esophagus. Barium test and gastrograffin test may also be used for diagnosing perforation in the esophagus.
Treatment :
The rate of survival is very low in Boerhaave syndrome. Untreated cases are mostly mortal. Once diagnosed with esophageal rupture, antibiotic therapy is to be given to prevent sepsis which is followed by surgical repair of esophagus. Risk of fatality is 20-25% even with prompt surgery. The chances of survival depend on intensity of perforation and location.
The patient should be put on IV fluids immediately to start antibiotic therapy and if necessary nasogastric suction can be done followed by surgery. Left thoractomy is done for early diagnosis. Stents or alternative tubing can be used to divert the passage of esophagus. Self expanding metallic stents are used nowadays to bridge the tear of esophagus.
Prognosis :
Recovery of the person with Boerhaave syndrome is doubtful. It depends on the site of injury and the intensity of tear on the esophagus.
