Boerhaave Syndrome Treatment & Management

  • Author: Praveen K Roy, MD, AGAF; Chief Editor: Julian Katz, MD   more...
 
Updated: Aug 18, 2011
 

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: Evidence suggests that for hastening recovery, a jejunostomy tube feeding may be favored over hyperalimentation.
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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 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.[6, 7]
    • 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. 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
  • Based on a review of published literature, de Schipper et al recommended endoscopic treatment of Boerhaave syndrome in certain cases.[2] The authors determined that the survival rates for conservative, surgical, and endoscopic treatments for Boerhaave syndrome are, respectively, 75%, 81%, and 100%. They concluded that patients should be treated endoscopically when the condition has been diagnosed within 48 hours of the esophageal rupture, provided that there are no signs of sepsis. If the diagnosis is made within 48 hours of rupture but the patient has a septic profile, the investigators recommended that thoracotomy with hemifundoplication and pleural/mediastinal drainage be performed.
  • Intra-abdominal leakage necessitates local repair via laparotomy, according to de Schipper and colleagues. They also recommended that patients who are diagnosed more than 48 hours after esophageal rupture should undergo conservative therapy, with surgical treatment employed in these patients only when they have a septic profile.
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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.
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Contributor Information and Disclosures
Author

Praveen K Roy, MD, AGAF  Gastroenterologist, Ochsner Clinic Foundation; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute; Editor-in-Chief, The Internet Journal of Gasteroenterology; Editorial Board, Signal Transduction Insights; Editorial Board, The Internet Journal of Epidemiology; Editorial Board, Gastrointestinal Endoscopy Review Letter

Praveen K Roy, MD, AGAF is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

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 Physician, Department of Internal Medicine, University Hospital of Missouri-Columbia

Abhishek Choudhary, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Mohamed Othman, MD  Resident 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  Associate Professor, Department of Clinical Medicine, University of Missouri School of Medicine

Jack Bragg, DO 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.

Showkat Bashir, MD  Assistant Professor, Department of Medicine, Division of Gastroenterology, George Washington University, Washington, DC

Showkat Bashir, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Manoop S Bhutani, MD  Professor, Co-Director, Center for Endoscopic Research, Training and Innovation (CERTAIN), Director, Center for Endoscopic Ultrasound, Department of Medicine, Division of Gastroenterology, University of Texas Medical Branch; Director, Endoscopic Research and Development, The University of Texas MD Anderson Cancer Center

Manoop S Bhutani, MD 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of 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

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Prakash Ramanathan, MD, to the development and writing of this article.

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