Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Boerhaave Syndrome Treatment & Management

  • Author: Praveen K Roy, MD, AGAF; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
 
Updated: Jul 06, 2015
 

Medical Care

Ideal management for Boerhaave syndrome 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.

Consultations

Consultation with a thoracic or general surgeon is indicated as soon as the diagnosis is suspected.

An Infectious disease specialist should be consulted for assistance with antimicrobial therapy.

Next

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, including the following:

  • 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] Note the following:

  • 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.

Previous
 
 
Contributor Information and Disclosures
Author

Praveen K Roy, MD, AGAF Chief of Gastroenterology, Presbyterian Hospital; Medical Director of Endoscopy, Presbyterian Medical Group; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute

Praveen K Roy, MD, AGAF is a member of the following medical societies: American Gastroenterological Association, American Society for 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, Southern Medical Association

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, American Medical Association

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, American Medical Association

Disclosure: Nothing to disclose.

Rahaman Mujibur, MD Academic Hospitalist/Hospitalist, Marshfield Clinic, St Joseph’s Hospital

Rahaman Mujibur, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Philip O Katz, MD, FACP, FACG Chairman, Division of Gastroenterology, Albert Einstein Medical Center; Clinical Professor of Medicine, Jefferson Medical College of Thomas Jefferson University

Philip O Katz, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Received honoraria from Takeda for speaking and teaching; Received consulting fee from Ironwood for consulting; Received consulting fee from Torax for consulting; Received consulting fee from Pfizer Consumer Health for consulting.

Additional Contributors

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, American Society for Gastrointestinal Endoscopy

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.

Acknowledgements

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

References
  1. Korn O, Onate JC, Lopez R. Anatomy of the Boerhaave syndrome. Surgery. 2007 Feb. 141(2):222-8. [Medline].

  2. de Schipper JP, Pull ter Gunne AF, Oostvogel HJ, van Laarhoven CJ. Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Dig Surg. 2009. 26(1):1-6. [Medline].

  3. Kish GF, Katske FA. A case of recurrent Boerhaave's syndrome. W V Med J. 1980 Feb. 76(2):27-30. [Medline].

  4. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. 1986 Sep. 42(3):235-9. [Medline].

  5. Restrepo CS, Lemos DF, Ocazionez D, Moncada R, Gimenez CR. Intramural hematoma of the esophagus: a pictorial essay. Emerg Radiol. 2008 Jan. 15(1):13-22. [Medline].

  6. Ghassemi KF, Rodriguez HJ, Vesga L, et al. Endoscopic treatment of Boerhaave syndrome using a removable self-expandable plastic stent. J Clin Gastroenterol. 2007 Oct. 41(9):863-4. [Medline].

  7. Zisis C, Guillin A, Heyries L, et al. Stent placement in the management of oesophageal leaks. Eur J Cardiothorac Surg. 2008 Mar. 33(3):451-6. [Medline].

  8. Adam A, Watkinson AF, Dussek J. Boerhaave syndrome: to treat or not to treat by means of insertion of a metallic stent. J Vasc Interv Radiol. 1995 Sep-Oct. 6(5):741-3; discussion 744-6. [Medline].

  9. Adams BD, Sebastian BM, Carter J. Honoring the Admiral: Boerhaave-van Wassenaer's syndrome. Dis Esophagus. 2006. 19(3):146-51. [Medline].

  10. Bjerke HS. Boerhaave's syndrome and barogenic injuries of the esophagus. Chest Surg Clin N Am. 1994 Nov. 4(4):819-25. [Medline].

  11. Bonheim N, Alavi I. Boerhaave's syndrome: spontaneous rupture of the esophagus. Chic Med Sch Q. 1970. 29(1):31-6. [Medline].

  12. Chiu CL, Gambach RR. Spontaneous perforation of the esophagus (Boerhaave's syndrome). J Iowa Med Soc. 1973 Sep. 63(9):436-8. [Medline].

  13. Clark W, Cook IJ. Spontaneous intramural haematoma of the oesophagus: radiologic recognition. Australas Radiol. 1996 Aug. 40(3):269-72. [Medline].

  14. Craven GG, Whittaker MG. Boerhaave's syndrome as a complication of pre-existent gastrointestinal disease. Ir J Med Sci. 1992 Dec. 161(12):670-4. [Medline].

  15. Crookes PF. RE: Hermann Boerhaave: the man behind the syndrome. Dis Esophagus. 1997 Oct. 10(4):303. [Medline].

  16. Curtis DL, Burbige EJ, Milligan FD. Boerhaave's syndrome: role of esophagoscopy. Gastrointest Endosc. 1976 May. 22(4):208-9. [Medline].

  17. Datta CK, Brannon JV. Spontaneous rupture of esophagus (Boerhaave syndrome): a review of literature and a case presentation. W V Med J. 1979 Jul. 75(7):180-2. [Medline].

  18. Davies AP, Vaughan R. Expanding mesh stent in the emergency treatment of Boerhaave's syndrome. Ann Thorac Surg. 1999 May. 67(5):1482-3. [Medline].

  19. Davis R. The Boerhaave syndrome associated with carcinoma of the oesophagus. S Afr Med J. 1973 Dec 1. 47(47):2269-72. [Medline].

  20. Drury M, Anderson W, Heffner JE. Diagnostic value of pleural fluid cytology in occult Boerhaave's syndrome. Chest. 1992 Sep. 102(3):976-8. [Medline].

  21. Duehring GL. Boerhaave syndrome. Radiol Technol. 2000 Sep-Oct. 72(1):51-5. [Medline].

  22. Dumonceau JM, Deviere J, Cappello M, et al. Endoscopic treatment of Boerhaave's syndrome. Gastrointest Endosc. 1996 Oct. 44(4):477-9. [Medline].

  23. Eubanks PJ, Hu E, Nguyen D, Procaccino F, et al. Case of Boerhaave's syndrome successfully treated with a self-expandable metallic stent. Gastrointest Endosc. 1999 Jun. 49(6):780-3. [Medline].

  24. Hansen CP, Bertelsen S. Boerhaave's syndrome: spontaneous rupture of the oesophagus. Ann Chir Gynaecol. 1988. 77(4):138-41. [Medline].

  25. Henderson JA, Peloquin AJ. Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader. Am J Med. 1989 May. 86(5):559-67. [Medline].

  26. Jagminas L, Silverman RA. Boerhaave's syndrome presenting with abdominal pain and right hydropneumothorax. Am J Emerg Med. 1996 Jan. 14(1):53-6. [Medline].

  27. Janjua KJ. Boerhaave's syndrome. Postgrad Med J. 1997 May. 73(859):265-70. [Medline].

  28. Jenkins IR, Raymond R. Boerhaave's syndrome complicated by a large bronchopleural fistula. Chest. 1994 Mar. 105(3):964-5. [Medline].

  29. John BE, Zua MS. Boerhaave's syndrome--an elusive diagnosis. Tenn Med. 1997 Feb. 90(2):56-8. [Medline].

  30. Kallis P, Belsham PA, Pepper JR. Spontaneous rupture of the oesophagus (Boerhaave's syndrome): conservative versus surgical management. J R Soc Med. 1991 Nov. 84(11):690-1. [Medline].

  31. Klausner JM, Epstein L, Peer G, et al. Perforation of the esophagus (Boerhaave's syndrome) during hemodialysis. Nephron. 1985. 40(3):372-3. [Medline].

  32. Klin B, Berlatzky Y, Uretzky G. Boerhaave's syndrome: case report and review of the literature. Isr J Med Sci. 1989 Feb. 25(2):113-5. [Medline].

  33. Kyriacou DN. A case of Boerhaave's syndrome presenting as diffuse left pulmonary infiltrate. Ann Emerg Med. 1991 Nov. 20(11):1239-42. [Medline].

  34. Lawrence DR, Ohri SK, et al. Primary esophageal repair for Boerhaave's syndrome. Ann Thorac Surg. 1999. 67(3):818-20. [Medline].

  35. Levinsky L, Adler RH. Recurrent diagphragmatic herniation: following gastric onlay reinforcement of esophageal rupture (Boerhaave syndrome). N Y State J Med. 1980 Feb. 80(2):244-8. [Medline].

  36. Levy F, Mysko WK, Kelen GD. Spontaneous esophageal perforation presenting with right-sided pleural effusion. J Emerg Med. 1995 May-Jun. 13(3):321-5. [Medline].

  37. Lin WC, Chen JD, Tiu CM, et al. Boerhaave syndrome with atypical clinical presentations diagnosed by computed tomography. Zhonghua Yi Xue Za Zhi (Taipei). 2002 Jan. 65(1):45-8. [Medline].

  38. Lujan HJ, Lin PH, Boghossian SP, et al. Recurrent spontaneous rupture of the esophagus: an unusual late complication of Boerhaave's syndrome. Surgery. 1997 Sep. 122(3):634-6. [Medline].

  39. Marshall WB. Boerhaave syndrome: a case report. AANA J. 2002 Aug. 70(4):289-92. [Medline].

  40. McCartney J, Dobrow J, Hendrix TR. Boerhaave syndrome. Johns Hopkins Med J. 1979 Jan. 144(1):28-33. [Medline].

  41. Meyer GW, Castell DO. Evaluation and management of diseases of the esophagus. Am J Otolaryngol. 1981 Nov. 2(4):336-44. [Medline].

  42. Michel L. Post-emetic laceration and rupture of the gastroesophageal junction. Acta Chir Belg. 1982 Jan-Feb. 82(1):13-24. [Medline].

  43. Munemura T, Suzuki O, Ootake S, et al. A rare case of spontaneous esophageal rupture (Boerhaave's syndrome) associated with pulmonary rupture. Jpn J Thorac Cardiovasc Surg. 1998 Nov. 46(11):1074-7. [Medline].

  44. Pezzulli FA, Aronson D, Goldberg N. Computed tomography of mediastinal hematoma secondary to unusual esophageal laceration: a Boerhaave variant. J Comput Assist Tomogr. 1989 Jan-Feb. 13(1):129-31. [Medline].

  45. Phillips LG Jr, Cogbill CL, Makkar JC, et al. Barogenic rupture of the esophagus (Boerhaave's syndrome): successful treatment of a late case. Am Surg. 1982 Aug. 48(8):430-4. [Medline].

  46. Rogers LF, Puig AW, Dooley BN, et al. Diagnostic considerations in mediastinal emphysema: a pathophysiologic-roentgenologic approach to Boerhaave's syndrome and spontaneous pneumomediastinum. Am J Roentgenol Radium Ther Nucl Med. 1972 Jul. 115(3):495-511. [Medline].

  47. Rozycki GS. Image of the month. Esophageal perforation (Boerhaave syndrome). Arch Surg. 2001 Mar. 136(3):355-6. [Medline].

  48. Sabanathan S, Eng J, Richardson J. Surgical management of intrathoracic oesophageal rupture. Br J Surg. 1994 Jun. 81(6):863-5. [Medline].

  49. Sakamoto Y, Tanaka N, Furuya T, et al. Surgical management of late esophageal perforation. Thorac Cardiovasc Surg. 1997 Dec. 45(6):269-72. [Medline].

  50. Salim AS. Jejunostomy feeding for the conservative management of spontaneous rupture of the oesophagus. Br J Clin Pract. 1991 Spring. 45(1):37-40. [Medline].

  51. Salo JA, Seppala KM, Pitkaranta PP, et al. Spontaneous rupture and functional state of the esophagus. Surgery. 1992 Nov. 112(5):897-900. [Medline].

  52. Scott HJ, Rosin RD. Thoracoscopic repair of a transmural rupture of the oesophagus (Boerhaave's syndrome). J R Soc Med. 1995 Jul. 88(7):414P-415P. [Medline].

  53. Singh GS, Slovis CM. "Occult" Boerhaave's syndrome. J Emerg Med. 1988 Jan-Feb. 6(1):13-6. [Medline].

  54. Smyth AR, Wastell C. Spontaneous rupture of the oesophagus (Boerhaave's syndrome): delayed diagnosis and successful conservative management. J R Soc Med. 1989 Aug. 82(8):498. [Medline].

  55. Troum S, Lane CE, Dalton ML Jr. Surviving Boerhaave's syndrome without thoracotomy. Chest. 1994 Jul. 106(1):297-9. [Medline].

  56. van Gijn J, Gijselhart JP. [Boerhaave and his syndrome]. Ned Tijdschr Geneeskd. 2013. 157(4):A5460. [Medline].

  57. Van Nooten G, Azagra JS, Alle JL, et al. Spontaneous rupture of the esophagus after coronary artery bypass. Acta Chir Belg. 1987 Nov-Dec. 87(6):367-70. [Medline].

  58. Weil RJ. Candidal mediastinitis after surgical repair of esophageal perforation. South Med J. 1991 Aug. 84(8):1052-3. [Medline].

  59. White RK, Morris DM. Diagnosis and management of esophageal perforations. Am Surg. 1992 Feb. 58(2):112-9. [Medline].

  60. Zawisza MJ, Geisler A. Spontaneous rupture of esophagus (Boerhaave's syndrome): case report and literature review. J Am Osteopath Assoc. 1988 Jun. 88(6):787-90. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.