Boerhaave Syndrome Clinical Presentation

Updated: Dec 06, 2018
  • Author: Praveen K Roy, MD, AGAF; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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Presentation

History

The classic clinical presentation of Boerhaave syndrome usually consists of repeated episodes of retching and vomiting, typically in a middle-aged man with recent excessive dietary and alcohol intake.

These repeated episodes of retching and vomiting are followed by a sudden onset of severe chest pain in the lower thorax and the upper abdomen. The pain may radiate to the back or to the left shoulder. Swallowing often aggravates the pain.

Typically, hematemesis is not seen after esophageal rupture, which helps to distinguish it from the more common Mallory-Weiss tear.

Swallowing may precipitate coughing because of the communication between the esophagus and the pleural cavity.

Atypical clinical features sometimes delay obtaining a prompt diagnosis and the adminstration of appropriate intervention. This may result in an increase in morbidity and mortality.

Shortness of breath is a common complaint and is due to pleuritic pain or pleural effusion.

Other conditions to consider include spontaneous intramural esophageal perforation and spontaneous intramural hematoma of the esophagus (esophageal apoplexy). [8]

Next:

Physical Examination

Although the Mackler triad of vomiting, lower thoracic pain, and subcutaneous emphysema is the classic presentation of Boerhaave syndrome, this triad is actually rare, which may then lead to a delay in diagnosis. [9]  

Patients' presentation may vary depending on the following:

  • The location of the tear

  • The cause of the injury

  • The amount of time that has passed from the perforation to the intervention

Patients with cervical esophagus perforation may present with neck or upper chest pain.

Patients with middle or lower esophagus perforation may present with interscapular or epigastric discomfort.

Findings of pleural effusion are common.

If present, subcutaneous emphysema is particularly helpful in confirming the diagnosis. This feature is seen in 28-66% of patients at initial presentation. More typically, subcutaneous emphysema is found later.

Other classic findings include tachypnea and abdominal rigidity.

Tachycardia, diaphoresis, fever, and hypotension are common, particularly as the illness progresses. However, these findings are nonspecific.

Unusual findings may include the following:

  • Peripheral cyanosis

  • Hoarseness of the voice due to recurrent laryngeal nerve involvement

  • Tracheal and mediastinal shift

  • Cervical vein distention

  • Proptosis

Pneumomediastinum is a very important finding. It may cause a crackling sound upon chest auscultation, known as the Hamman crunch. The crunch is typically heard coincident with each heartbeat and may be mistaken for a pericardial friction rub. This is present in 20% of patients.

Later stages of the illness may manifest with signs of infection and sepsis. Symptoms may include fever, hemodynamic instability, and progressive obtundation. Establishing a diagnosis in the later stages can be quite difficult, because septic complications begin to dominate the clinical picture. Again, early diagnosis is critical.

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