Boerhaave Syndrome

Description

• Also known as effort rupture of the esophagus
• Spontaneous esophageal rupture from sudden combined increase in intra-abdominal pressure and negative intrathoracic pressure
  • Causes complete, full-thickness (transmural), longitudinal tear in esophagus
• Esophagus has no serosal layer (which normally contains collagen and elastic fibers):
  • Results in weak structure vulnerable to perforation and mediastinal contamination
  • Esophageal wall is further weakened by conditions that damage mucosa (i.e., esophagitis is of various causes)
• Majority of perforations occur at left posterolateral wall of the lower third esophagus
• Significant morbidity/mortality (most lethal GI tract perforation):
  • Owing to explosive nature of tear
  • Owing to almost immediate contamination of mediastinum with contents of esophagus
  • Overall mortality can approach 35%
  • Mortality can double if treatment is delayed >24 hr from rupture
  • Cervical rupture associated with the lowest mortality, followed by abdominal and thoracic rupture, respectively

Etiology

• Associated with:
  • Forceful vomiting and retching (most common)
  • Heavy lifting
  • Seizures
  • Childbirth
  • Blunt trauma
  • Induced emesis
  • Caustic ingestions
  • Laughing
  • History of Barrett or infectious ulcer
  • History of HIV/AIDS
  • History of eosinophilic or pill esophagitis
  • History of esophageal cancer
• Common in middle-aged men
• Medical procedures cause over 50% of all perforations

• Described in female neonates but rarely seen
• Consider caustic ingestions