eMedicine Specialties > Gastroenterology > Esophagus

Boerhaave Syndrome: Differential Diagnoses & Workup

Author: Praveen K Roy, MD, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group
Coauthor(s): Mark E Murphy, MD, FACP, Assistant Professor of Internal Medicine, Mercer University Medical School; Program Director, Gastroenterology and Hepatology Education, Department of Internal Medicine, Memorial Health University Medical Center; Abhishek Choudhary, MD, Resident, Department of Internal Medicine, University Hospital of Missouri; Mohamed Othman, MD, Staff Physician, Department of Internal Medicine, University of New Mexico School of Medicine; Viswanath Kalapatapu, MD, Staff Physician, Department of Internal Medicine, Memorial Health University Medical Center; Jack Bragg, DO, FACOI, Assistant Professor, Department of Clinical Medicine, University of Missouri School of Medicine; Gautam Dehadrai, MD, Department Chair, Section Chief, Department of Interventional Radiology, Norman Regional Hospital
Contributor Information and Disclosures

Updated: Aug 12, 2008

Differential Diagnoses

Aortic Dissection
Peptic Ulcer Disease
Esophageal Rupture
Pneumothorax
Mallory-Weiss Tear
Myocardial Infarction
Pancreatitis, Acute

Other Problems to Be Considered

Spontaneous intramural esophageal perforation
Spontaneous intramural hematoma of the esophagus (esophageal apoplexy)

Workup

Laboratory Studies

  • Laboratory findings often are nonspecific.
  • Patients may present with leukocytosis and a left shift.
  • As many as 50% of patients with Boerhaave syndrome have a hematocrit value that approaches 50%. This may be due to fluid loss into pleural spaces and tissues.
  • Serum albumin is normal but may be low, while the globulin fraction may be normal or slightly elevated.
  • Many patients present with a pleural effusion.
    • Thoracentesis with examination of the pleural fluid can aid in diagnosis.
    • Undigested food particles and gastric juices usually are found.
    • If no gross particles are found, cytology can confirm or exclude their presence, but time is of the essence.
    • The pH of the pleural fluid will be less than 6, and the amylase content will be elevated.
    • Squamous cells from saliva may be found.

Imaging Studies

  • Upright chest radiograph
    • This is useful in the initial diagnosis because 90% of patients reveal an abnormal finding after perforation.
    • The most common finding is a unilateral effusion, usually on the left. This corresponds with the fact that most perforations occur in the left posterior aspect of the esophagus.
    • Other findings may include pneumothorax, hydropneumothorax, pneumomediastinum, subcutaneous emphysema, or mediastinal widening.
    • The V-sign of Naclerio has been described as a chest radiograph finding in as many as 20% of patients. This involves the presence of radiolucent streaks of air that dissect the fascial planes behind the heart to form the shape of the letter V. It is a fairly specific, although insensitive, radiographic sign of esophageal perforation.
    • Overall, 10% of chest radiographs are normal. This can be at least partly explained by the delayed radiographic development of mediastinal and subcutaneous emphysema. These findings may take an hour or more after perforation to appear on the chest radiograph.
  • Esophagram
    • This helps confirm the diagnosis.
    • It typically shows extravasation of contrast into the pleural cavity.
    • An esophagram outlines the length of the perforation and its location, which aids in the decision of whether to use a thoracic or abdominal surgical approach.
    • Initially, use a water-soluble contrast, such as Gastrografin. It has 90% sensitivity.
    • It may have false-negative results in up to 20% of patients.
    • The use of barium in patients affected with Boerhaave syndrome has been associated with severe mediastinitis. This complication may contribute significantly to increased morbidity and mortality.
    • If the contrast study is negative and the clinical index of suspicion remains high, placing the patient in the left and right lateral decubitus positions often is helpful. The use of barium would then be warranted.
  • CT scan
    • It can reveal decisive criteria for diagnosis.
    • It is helpful in patients too ill to tolerate esophagrams.
    • It localizes collections of fluid for surgical drainage.
    • Visualization of adjacent structures is possible, which expands the differential diagnosis in patients with chest pain and vomiting.
    • It can demonstrate periesophageal air tracks that are suggestive of perforation.
    • CT scan may not precisely localize the site of perforation.

Procedures

  • Endoscopy is not commonly used to aid in diagnosis of Boerhaave syndrome.
    • It carries the additional risks of increasing the size and extent of the original perforation and forcing additional air through the perforation into the mediastinum or pleural cavity.
    • It is more useful in the thoracic esophagus because it has poor sensitivity in the cervical esophagus.
    • Endoscopy may be useful when a perforation is suspected but not proven, especially when trauma (eg, ingested foreign body) is known or suspected to be present.

More on Boerhaave Syndrome

Overview: Boerhaave Syndrome
Differential Diagnoses & Workup: Boerhaave Syndrome
Treatment & Medication: Boerhaave Syndrome
Follow-up: Boerhaave Syndrome
References
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Further Reading

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Keywords

Boerhaave syndrome, Boerhaave's syndrome, esophageal perforation, esophageal rupture, perforated esophagus, esophagus perforation, esophagus rupture, ruptured esophagus, esophagus tear, esophageal tear, spontaneous esophageal rupture, spontaneous rupture of the esophagus, transmural perforation of the esophagus, forceful emesis, emesis complications

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Contributor Information and Disclosures

Author

Praveen K Roy, MD, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group
Praveen K Roy, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and Canadian Association of Gastroenterology
Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Murphy, MD, FACP, Assistant Professor of Internal Medicine, Mercer University Medical School; Program Director, Gastroenterology and Hepatology Education, Department of Internal Medicine, Memorial Health University Medical Center
Mark E Murphy, MD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Medical Association of Georgia, and Southern Medical Association
Disclosure: Nothing to disclose.

Abhishek Choudhary, MD, Resident, Department of Internal Medicine, University Hospital of Missouri
Abhishek Choudhary, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Mohamed Othman, MD, Staff Physician, Department of Internal Medicine, University of New Mexico School of Medicine
Disclosure: Nothing to disclose.

Viswanath Kalapatapu, MD, Staff Physician, Department of Internal Medicine, Memorial Health University Medical Center
Viswanath Kalapatapu, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Jack Bragg, DO, FACOI, Assistant Professor, Department of Clinical Medicine, University of Missouri School of Medicine
Jack Bragg, DO, FACOI is a member of the following medical societies: American College of Osteopathic Internists and American Osteopathic Association
Disclosure: Nothing to disclose.

Gautam Dehadrai, MD, Department Chair, Section Chief, Department of Interventional Radiology, Norman Regional Hospital
Gautam Dehadrai, MD is a member of the following medical societies: American College of Radiology, Medical Council of India, and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Manoop S Bhutani, MD, FACG, FACP, Professor, Department of Medicine, Division of Gastroenterology, Director, Center for Endoscopic Ultrasound, Co-Director, Center for Endoscopic Research, Training and Innovation, University of Texas Medical Branch at Galveston
Manoop S Bhutani, MD, FACG, FACP is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Institute of Ultrasound in Medicine, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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