From the Guidelines
Boerhaave syndrome is a severe and potentially life-threatening condition characterized by a spontaneous rupture of the esophagus, often due to intense vomiting or straining, accounting for 15% of esophageal perforations 1. Immediate medical attention is crucial.
Recommendation
- Patients with suspected Boerhaave syndrome should be hospitalized and closely monitored.
- Intravenous antibiotics, such as ceftriaxone 1g every 12 hours and metronidazole 500mg every 8 hours, should be administered to prevent infection.
- Pain management with medications like morphine 2-4mg every 4 hours as needed is essential.
- Patients should be kept nil per os (nothing by mouth) until further evaluation.
- Endoscopy or imaging studies like CT scans may be necessary for diagnosis, with CT esophagogram having high sensitivity (95%) and specificity (91%) rates in detecting upper digestive tract perforation 1.
- Surgical intervention is often required to repair the esophageal tear, and the timing of surgery depends on the patient's condition and the severity of the rupture.
- In some cases, conservative management with antibiotics and supportive care may be considered, but this approach is typically reserved for very small, contained leaks without significant mediastinal contamination. Key considerations include the location of the tear, usually on the left border of the lower third of the thoracic esophagus, and the size of the wall defect, which can be large (3–8 cm) 1.
From the Research
Definition and Characteristics of Boerhaave Syndrome
- Boerhaave syndrome is a life-threatening spontaneous esophageal rupture, usually in its distal part 2, 3, 4, 5.
- It generally develops after situations that suddenly increase the intraesophageal pressure, such as during or after persistent vomiting 2, 6.
- The condition has a high mortality rate, ranging from 18-39% 2, and delayed diagnosis and treatment are the principal causes of high mortality 2.
Causes and Risk Factors
- Boerhaave syndrome can be caused by a combination of factors, including hypopharyngeal stenosis and chemoradiotherapy for hypopharyngeal cancer, which can lead to vomiting, edema, and relaxation failure 6.
- Patients with head and neck cancer are at risk for developing Boerhaave syndrome during chemoradiotherapy 6.
Treatment Options
- Treatment can be approached conservatively, endoscopically, or surgically 2.
- The more invasive the treatment, the worse the prognosis 2.
- Minimally invasive approaches, including thoracoscopic, endoscopic, and laparoscopic management, are safe and effective 4.
- Non-operative management strategies, including stent placement and endoluminal vacuum therapy, can be successful in selected patients 5.
Diagnosis and Management
- Diagnosis is often delayed, and mortality is significantly higher in late-diagnosed patients 3.
- Priority should be given to closure of the defect combined with drainage, while considering individual patient factors, including advanced age 3.
- A selective management algorithm involving a minimally invasive approach can be effective in managing Boerhaave syndrome 4.