Correspondence

Boerhaave's Syndrome

N Engl J Med 2001; 344:138-139January 11, 2001

Article

To the Editor:

Gopalan and Cooke (July 20 issue)1 describe a case of Boerhaave's syndrome that raises several questions. Usually, Boerhaave's syndrome presents as spontaneous esophageal rupture with perforation into the left side of the thorax, nearly always after severe vomiting. The patients typically are in acute distress and have a left-sided pleural effusion. Treatment usually consists of left-sided thoracotomy, with closure of the tear and flap coverage.2 Other therapeutic options include repair through an abdominal approach with chest-tube drainage or stenting of the esophagus. In the case described by Gopalan and Cooke, the patient was treated with bilateral thoracotomy and placement of chest tubes. The radiologic finding consisted of pneumomediastinum, but no extravasation of contrast medium was demonstrated. This report could represent a case of spontaneous pneumomediastinum, whose clinical presentation is identical to that described by Gopalan and Cooke and which has various causes.3

Herman Nehoda, M.D.
Katherine Hourmont, M.D.
University of Innsbruck Hospital, 6020 Innsbruck, Austria

3 References

1. 1

   Gopalan R, Cooke CG. Boerhaave's syndrome. N Engl J Med 2000;343:190-190
   Full Text | Web of Science | Medline

2. 2

   Mai C, Nagel M, Saeger HD. Die chirurgische Therapie de Oesophagusperforation: Eine Standort bestimmung anhand von 4 eigenen Fällen und der Literatur. Chirurg 1997;68:389-394
   CrossRef | Web of Science | Medline

3. 3

   Panacek EA, Singer AJ, Sherman BW, Prescott A, Rutherford WF. Spontaneous pneumomediastinum: clinical and natural history. Ann Emerg Med 1992;21:1222-1227
   CrossRef | Web of Science | Medline

To the Editor:

The term “Boerhaave's syndrome” is most appropriately applied to postemetic rupture of the esophagus; however, Gopalan and Cooke do not mention whether their patient had emesis. The syndrome was originally described in 1724 by Hermann Boerhaave, professor of medicine at Leiden University.1 The publication was entitled “History of a Grievous Disease Not Previously Described” and discussed the case of Baron Jan van Wassenaer, grand admiral of the Holland fleet, in whom severe pain developed after an episode of self-induced vomiting. The perforation is typically a linear tear in the left lateral wall of the esophagus just above the diaphragm. When Boerhaave's syndrome is suspected, a contrast esophagogram should be obtained and, in the absence of contraindications, primary repair should be attempted.2-4

Richard I. Whyte, M.D.
Stanford University School of Medicine, Stanford, CA 94305-5407

4 References

1. 1

   Derbes VJ, Mitchell RE Jr. Hermann Boerhaave's (1) Atrocis, nec Descripti Prius, Morbi Historia (2): the first translation of the classic case report of rupture of the esophagus, with annotations. Bull Med Libr Assoc 1955;43:217-217
   Medline

2. 2

   Wright CD, Mathisen DJ, Wain JC, Moncure AC, Hilgenberg AD, Grillo HC. Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg 1995;60:245-249
   CrossRef | Web of Science | Medline

3. 3

   Lawrence DR, Ohri SK, Moxon RE, Townsend ER, Fountain SW. Primary esophageal repair for Boerhaave's syndrome. Ann Thorac Surg 1999;67:818-820
   CrossRef | Web of Science | Medline

4. 4

   Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal perforation: the merit of primary repair. J Thorac Cardiovasc Surg 1995;109:140-146
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors and a colleague reply:

To the Editor: Our patient presented to the emergency department about four hours after eating a bacon sandwich and attempting to burp. This effort was followed by a burning substernal pain in his chest that radiated subcostally on both sides toward his back. His electrocardiogram showed lateral ST-segment depressions and Q waves in the inferior leads, with normal cardiac-enzyme levels. He had tachypnea and was admitted to the intensive care unit. The inferior mediastinal images of the computed tomographic (CT) scan (which were not shown) revealed extravasation of both air and contrast medium into the mediastinum. A posterior, necrotic esophageal tear was seen intraoperatively. The published image, obtained at the level of the first rib, showed extraesophageal air, which is regarded by some as the most useful finding on CT scanning.1,2

Boerhaave's syndrome (spontaneous rupture of the esophagus) is one cause of pneumomediastinum, and its presentation does not always follow the classic description. Emesis is documented in fewer than 80 percent of cases in the large series reported in the literature.3,4 The presentation of spontaneous pneumomediastinum, which is commonly associated with Valsalva's maneuver, is similar but not identical to that of Boerhaave's syndrome. Although primary repair is the recommended treatment for spontaneous esophageal perforation, mediastinal toilet and drainage by thoracotomy with placement of chest tubes is an acceptable alternative when repair is not possible.5 After thoracotomy, our patient received ventilatory support for several days, antibiotics, and total parenteral alimentation until a contrast esophagogram showed that he had recovered.

Ramana Gopalan, M.D., M.P.H.
Colleen G. Cooke, M.D.
Daniel P. Harley, M.D.
Greater Baltimore Medical Center, Baltimore, MD 21204

5 References

1. 1

   White CS, Templeton PA, Attar S. Esophageal perforation: CT findings. AJR Am J Roentgenol 1993;160:767-770
   Web of Science | Medline

2. 2

   Lee S, Mergo PJ, Ros PR. The leaking esophagus: CT patterns of esophageal rupture, perforation, and fistulization. Crit Rev Diagn Imaging 1996;37:461-490
   Medline

3. 3

   Pate JW, Walker WA, Cole FH Jr, Owen EW, Johnson WH. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989;47:689-692
   CrossRef | Web of Science | Medline

4. 4

   Brauer RB, Liebermann-Meffert D, Stein HJ, Bartels H, Siewert JR. Boerhaave's syndrome: analysis of the literature and report of 18 new cases. Dis Esophagus 1997;10:64-68
   Medline

5. 5

   Lawrence DR, Ohri SK, Moxon RE, Townsend ER, Fountain SW. Primary esophageal repair for Boerhaave's syndrome. Ann Thorac Surg 1999;67:818-820
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Achim Hochlehnert, Bernd Löwe, Hans-Bernd Bludau, Mathias Borst, Stephan Zipfel, Wolfgang Herzog. (2010) Spontaneous pneumomediastinum in anorexia nervosa: A case report and review of the literature on pneumomediastinum and pneumothorax. European Eating Disorders Review 18:2, 107-115
   CrossRef