Boerhaave syndrome: a diagnostic conundrum

Abstract

A 79-year-old man presented to the Emergency Department with abdominal pain 1 day after an elective total knee replacement. The patient was confused and drowsy, with a high fever, hypotension and uncontrolled atrial fibrillation. He subsequently developed respiratory failure, requiring admission to intensive care. It was then noted that a large pleural effusion had developed between two chest radiographs performed only 4 h apart. A pigtail catheter inserted into the pleural space revealed a transudate of pH 7.0 with an amylase of 17 220 U (serum amylase 54 U), and thus a diagnosis of spontaneous oesophageal rupture or Boerhaave syndrome was made. Despite drainage of the pleural space, the patient developed shock and multiorgan failure requiring mechanical ventilation, renal replacement therapy and cardiovascular support. The oesophageal leak was treated conservatively with intercostal tube drainage; the patient made a full recovery and was discharged from hospital 75 days later.

Figure 1

Semierect chest radiograph taken on admission showing bilateral pleural effusions and a tramline at the left heart border suggestive of a pneumomediastinum.

Figure 2

Semierect chest radiograph taken 4 h after that in fig 1 to check the correct positioning of a right subclavian line, showing massive enlargement of the right pleural effusion with veiling of the entire right hemithorax.

Figure 3

Tubing from the pleural drain (left) and nasogastric tube (right) showing identical contents.