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Boerhaave Syndrome Workup

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

Laboratory Studies

Laboratory findings often are nonspecific in patients with Boerhaave syndrome.

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.

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Imaging Studies

Upright chest radiography

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.

Esophagraphy

Esophagraphy helps to 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 on 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 scanning

CT scanning can reveal decisive criteria for diagnosis, it is helpful in patients too ill to tolerate esophagrams, and it localizes collections of fluid for surgical drainage. It can also demonstrate periesophageal air tracks that are suggestive of perforation, although it may not precisely localize the site of perforation.

Visualization of adjacent structures is possible, which expands the differential diagnosis in patients with chest pain and vomiting.

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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.

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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].

 
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