Boerhaave Syndrome

Basics

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 (ie, 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
ALERT

“Spontaneous” is a misnomer as it usually occurs after emesis, barogenic rupture is preferred term

Etiology

  • Associated with:
    • Forceful vomiting and retching (most common)
    • Heavy lifting
    • Seizures
    • Childbirth
    • Blunt trauma
    • Foreign bodies
    • 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
  • Over 60% of all perforations are iatrogenic (occur during therapeutic or diagnostic endoscopy)

Pediatric Considerations

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

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