Boerhaave Syndrome Workup

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

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.
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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.
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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  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.

References

  1. Korn O, Onate JC, Lopez R. Anatomy of the Boerhaave syndrome. Surgery. Feb 2007;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. Feb 1980;76(2):27-30. [Medline].

  4. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. Sep 1986;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. Jan 2008;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. Oct 2007;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. Mar 2008;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. Sep-Oct 1995;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. Nov 1994;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. Sep 1973;63(9):436-8. [Medline].

  13. Clark W, Cook IJ. Spontaneous intramural haematoma of the oesophagus: radiologic recognition. Australas Radiol. Aug 1996;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. Dec 1992;161(12):670-4. [Medline].

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

  16. Curtis DL, Burbige EJ, Milligan FD. Boerhaave's syndrome: role of esophagoscopy. Gastrointest Endosc. May 1976;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. Jul 1979;75(7):180-2. [Medline].

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

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

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

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

  22. Dumonceau JM, Deviere J, Cappello M, et al. Endoscopic treatment of Boerhaave's syndrome. Gastrointest Endosc. Oct 1996;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. Jun 1999;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. May 1989;86(5):559-67. [Medline].

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

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

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

  29. John BE, Zua MS. Boerhaave's syndrome--an elusive diagnosis. Tenn Med. Feb 1997;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. Nov 1991;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. Feb 1989;25(2):113-5. [Medline].

  33. Kyriacou DN. A case of Boerhaave's syndrome presenting as diffuse left pulmonary infiltrate. Ann Emerg Med. Nov 1991;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. Feb 1980;80(2):244-8. [Medline].

  36. Levy F, Mysko WK, Kelen GD. Spontaneous esophageal perforation presenting with right-sided pleural effusion. J Emerg Med. May-Jun 1995;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). Jan 2002;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. Sep 1997;122(3):634-6. [Medline].

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

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

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

  42. Michel L. Post-emetic laceration and rupture of the gastroesophageal junction. Acta Chir Belg. Jan-Feb 1982;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. Nov 1998;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. Jan-Feb 1989;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. Aug 1982;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. Jul 1972;115(3):495-511. [Medline].

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

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

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

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

  51. Salo JA, Seppala KM, Pitkaranta PP, et al. Spontaneous rupture and functional state of the esophagus. Surgery. Nov 1992;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. Jul 1995;88(7):414P-415P. [Medline].

  53. Singh GS, Slovis CM. "Occult" Boerhaave's syndrome. J Emerg Med. Jan-Feb 1988;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. Aug 1989;82(8):498. [Medline].

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

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

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

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

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

 
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