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Case Reports
. 2017 Jan-Feb;135(1):71-75.
doi: 10.1590/1516-3180.2016.0095220616. Epub 2016 Dec 12.

Boerhaave syndrome - case report

Biljana Radovanovic Dinic  1 , Goran Ilic  2 , Snezana Tesic Rajkovic  3 , Tatjana Jevtovic Stoimenov  4
Affiliations
Case Reports

Boerhaave syndrome - case report

Biljana Radovanovic Dinic et al. Sao Paulo Med J. 2017 Jan-Feb.

Abstract
in English, Portuguese

Context:: Boerhaave syndrome consists of spontaneous longitudinal transmural rupture of the esophagus, usually in its distal part. It generally develops during or after persistent vomiting as a consequence of a sudden increase in intraluminal pressure in the esophagus. It is extremely rare in clinical practice. In 50% of the cases, it is manifested by Mackler's triad: vomiting, lower thoracic pain and subcutaneous emphysema. Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Compared with ruptures of other parts of the digestive tract, spontaneous rupture is characterized by a higher mortality rate.

Case report:: This paper presents a 64-year-old female patient whose vomit was black four days before examination and became bloody on the day of the examination. Her symptoms included epigastric pain and suffocation. Physical examination showed hypotension, tachycardia, dyspnea and a swollen and painful abdomen. Auscultation showed lateral crackling sounds on inspiration. Ultrasound examination showed a distended stomach filled with fluid. Over 1000 ml of fresh blood was extracted by means of nasogastric suction. Esophagogastroduodenoscopy was discontinued immediately upon entering the proximal esophagus, where a large amount of fresh blood was observed. The patient was sent for emergency abdominal surgery, during which she died. An autopsy established a diagnosis of Boerhaave syndrome and ulceration in the duodenal bulb.

Conclusion:: Boerhaave syndrome should be considered in all cases with a combination of gastrointestinal symptoms (especially epigastric pain and vomiting) and pulmonary signs and symptoms (especially suffocation).

CONTEXTO:: A síndrome de Boerhaave é uma ruptura longitudinal transmural espontânea do esôfago, normalmente da parte distal. Ela geralmente se desenvolve durante ou após vômitos persistentes como consequência do aumento repentino da pressão intraluminal no esôfago. É extremamente rara na prática clínica. Em 50% dos casos, manifesta-se pela tríade de Mackler: vômitos, dor torácica inferior, enfisema subcutâneo. Hematêmese é uma apresentação incomum porém desafiadora da síndrome de Boerhaave. Em comparação com rupturas de outras partes do tubo digestivo, a ruptura espontânea é caracterizada pela taxa de mortalidade mais elevada.

RELATO DO CASO:: O artigo apresenta uma paciente do sexo feminino de 64 anos de idade, cujo vômito era preto, quatro dias antes do exame, e continha sangue no dia do exame. Os sintomas incluíam dor epigástrica e sufocação. No exame físico, foi verificada hipotensão, taquicardia, dispneia e abdômen inchado e doloroso. Ausculta revelou estertores laterais na inspiração. A ultrassonografia mostrou estômago dilatado, preenchido com conteúdo líquido. Sucção nasogástrica evacuou mais de 1.000 ml de sangue fresco. Esofagogastroduodenoscopia foi abortada imediatamente ao se entrar no esôfago proximal, onde foi observada grande quantidade de sangue fresco. A paciente foi encaminhada com urgência para cirurgia abdominal, durante a qual faleceu. Autópsia estabeleceu diagnóstico de síndrome de Boerhaave e úlcera no bulbo-duodenal.

CONCLUSÃO:: A síndrome Boerhaave deve ser considerada em todos os casos com uma combinação de sintomas gastrointestinais (especialmente dor epigástrica e vómitos) e sintomas e sinais pulmonares (especialmente sufocação).

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Conflict of interest statement

Conflict of interest: None

Figures

Figure 1:
Figure 1:. Macroscopic findings from the intrathoracic contents upon opening the thoracic cavity. Note the huge amount of clot.
Figure 2:
Figure 2:. Gross examination of the distal esophagus showing a longitudinal complete rupture 15 mm from the cardia. Note the darkened esophageal mucosa.
Figure 3:
Figure 3:. Gross findings from the stomach and duodenum showing deep and wide duodenal ulceration in the duodenal bulb (arrow).
Table 1:
Table 1:. Literature search in medical databases for case reports on Boerhaave syndrome. The literature search was conducted on May 4, 2016
See this image and copyright information in PMC

Comment in

References

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Publication types

Supplementary concepts