eMedicine Specialties > Gastroenterology > Esophagus

Boerhaave Syndrome: Treatment & Medication

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

Treatment

Medical Care

  • Ideal management involves a combination of both conservative and surgical interventions.
  • Mainstays of therapy include the following:
    • Intravenous volume resuscitation
    • Administration of broad-spectrum antibiotics
    • Prompt surgical intervention
  • The decision to use a conservative (medical intervention only) or an aggressive (medical plus surgical intervention) approach depends on the following factors:
    • Time delay in presentation and diagnosis
    • Extent of perforation
    • Overall medical condition of the patient
  • Surgical intervention is the standard of care in most cases, but Cameron et al established a set of criteria in which conservative (nonsurgical) management might be appropriate. These include the following:
    • The esophageal disruption should be well contained in the mediastinum.
    • The cavity should be well drained back into the esophagus.
    • Few symptoms should be present.
    • Evidence of clinical sepsis should be minimal.
  • Conservative management consists of the following:
    • Intravenous fluids should be instituted.
    • Antibiotics: Imipenem/cilastatin (Primaxin) offers good broad-spectrum coverage.
    • Nasogastric suction should be applied.
    • Keep the patient NPO.
    • Adequate drainage with tube thoracostomy or formal thoracotomy is vital.
    • Early use of nutritional supplementation: Recent evidence suggests that, for hastening recovery, a jejunostomy tube feeding may be favored over hyperalimentation.

Surgical Care

  • Barrett described the first successful surgical repair of the esophagus in 1947. Prior to this, Boerhaave syndrome had virtually 100% mortality.
  • Most physicians advocate surgical intervention if the diagnosis is made within the first 24 hours after perforation.
  • Direct repair of the rupture and adequate drainage of the mediastinum and pleural cavity provide the best survival rates.
  • A left thoracotomy is the preferred approach, although laparotomy may be necessary if the tear extends into the distal esophagus.
    • Various techniques, such as the use of an omental flap, may be used to support the primary closure.
    • Gastrostomy and jejunostomy tubes often are placed to aid in drainage and nutrition, respectively.
  • The vitality of the surrounding tissue is an important factor in selecting the surgical procedure.
    • For patients in whom a delay in diagnosis (>24 h) occurred, primary repair may not be possible.
    • After 24 hours, the wound edges frequently are edematous, stiff, and friable.
  • Various alternatives to primary repair are available.
    • The most common includes the creation of an esophageal diversion through the use of a loop or end-cervical esophagostomy. This allows the wound to heal by secondary intention.
    • The use of T-tubes also has been described. T-tubes result in the formation of a controlled fistula and a route for drainage of esophageal secretions and refluxed gastric materials.
    • One recent study noted that the option of primary repair may be considered for perforations as old as 72 hours.
  • Newer techniques involve the use of plastic-covered self-expanding metallic stents.
    • They are considered acceptable alternatives only when all other interventional options have been exhausted. Their use in nonmalignant disease is highly controversial because they cannot be removed without considerable risks or not at all.
    • The use of stents in Boerhaave syndrome is recommended for cases that involve extreme delays in diagnosis or a failure of conservative management.
    • Expandable metal stents are most commonly used as palliative interventions for unresectable malignant esophageal obstruction.
    • These devices bridge the esophageal tear.
    • Several types of stents are available, and they vary in flexibility. Recent research holds the promise of biodegradable stents, obviating the necessity for removal.
    • Esophageal stents have been associated with a risk of delayed massive hemorrhage in patients with esophageal malignancy.
    • The long-term effects of stent placement in Boerhaave syndrome have not been adequately evaluated.
  • Late complications of surgical intervention may include the following:
    • Empyema that often requires tube drainage or decortication
    • Esophagotracheal or esophagobronchial fistulas

Consultations

  • Consultation with a thoracic or general surgeon is indicated as soon as the diagnosis is suspected.
  • Infectious disease specialist should be consulted for assistance with antimicrobial therapy.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. A broad-spectrum antibiotic, such as imipenem/cilastatin (Primaxin), is recommended.


Imipenem/cilastatin (Primaxin)

Offers good broad-spectrum coverage. For treatment of multiple-organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.

Adult

Base initial dose on severity of infection, and administer in equally divided doses
250-500 mg IV q6h, not to exceed 3-4 g/d
Alternatively, 500-750 mg IM q12h or intra-abdominally

Pediatric

<12 years: Not established; 15-25 mg/kg/dose IV q6h suggested for >3 months
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d

Coadministration with cyclosporine may increase adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal insufficiency; avoid use in children <12 years

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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