A 38-Year-Old Man With Persistent Vomiting: USMLE Study Question

May 01, 2020

Boerhaave syndrome is a rare condition that has a high mortality. Boerhaave syndrome describes a spontaneous transmural perforation of the esophagus that usually results from the combination of below-atmospheric intrathoracic pressure along with an increase in intraesophageal pressure caused by vomiting or straining. Spontaneous esophageal perforation may also be secondary to caustic ingestion, Barrett ulcer, or infectious ulcers in immunocompromised patients. Most cases of Boerhaave syndrome present with the tear along the left posterolateral aspect of the distal esophagus extending for several centimeters.

Boerhaave syndrome is characterized clinically by vomiting and retching, often following excessive food or alcohol intake, followed by acute pain in the retrosternal chest and upper abdominal with odynophagia and coughing. If left unrecognized infectious complications such as mediastinitis, develop quickly and can lead to septic shock. The mortality rate if the diagnosis is delayed by 24 hours is 50%.

If Boerhaave syndrome is suspected, a plain chest radiograph is typically abnormal, with free mediastinal or peritoneal air. Later radiographic sequelae include pleural effusion with or without pneumothorax, widened mediastinum, and subcutaneous emphysema. The diagnosis can be confirmed with chest CT or esophagram using isotonic, water-soluble contrast.

Major Takeaway: Boerhaave syndrome is a rare but potentially fatal syndrome caused by spontaneous esophageal perforation that is usually seen in the setting of severe retching and vomiting. Patients present with acute and severe retrosternal pain.

Read more about Boerhaave syndrome.

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