Boerhaave Syndrome Workup

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

Laboratory Studies

Laboratory findings are often 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 the pleural spaces and tissues.

The level of serum albumin is often normal or it may be low, whereas 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 the diagnosis. Undigested food particles and gastric juices usually are found. If no gross particles are found, cytology can be used to 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

An upright chest x-ray is useful in the initial diagnosis, because in 90% of patients an abnormal finding after perforation is revealed.

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 free air in the mediastinum or peritoneum, 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.

Esophagography

Esophagography helps to confirm the diagnosis of Boerhaave syndrome. It typically shows extravasation of contrast material 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 medium, such as Gastrografin. It has 90% sensitivity but 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 is often helpful. The use of barium would then be warranted.

Computed tomography (CT) scanning

CT scanning can reveal decisive criteria for the diagnosis. It is helpful in patients too ill to tolerate esophagrams, and it localizes collections of fluid for surgical drainage. This imaging modality can also demonstrate periesophageal air tracks that are suggestive of perforation, although it may not precisely localize the exact 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 the diagnosis of Boerhaave syndrome. Its role is controversial because 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 endoscopy 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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