Diagnostic challenge and surgical management of Boerhaave’s syndrome: three diagnosed cases of spontaneous esophageal rupture
Authors: Wang Jiayue , Wang Degang , Chen Jianjiao 
Published: September 2020

Abstract
BACKGROUND: Boerhaave’s syndrome is the spontaneous rupture of the esophagus, caused by an increase of intraluminal pressure that is produced in the context of negative intrathoracic pressure. It has a high index of morbimortality, which is why it requires early diagnosis and treatment. Symptoms may vary, and diagnosis can be challenging.CASE PRESENTATION: Case one: A 54-year-old man presented to us with sudden-onset epigastric pain radiating to the back following hematemes. His previous medical history included gastric ulcer. His physical signs suggested early shock. Combined with his medical history and physical signs, emergency doctor suspected a diagnosis of peptic ulcer with hematemesis, and esophagegastroscopy was performed. However, upper gastrointestinal endoscopy revealed a full-thickness rupture of the esophageal wall. The subsequent computed tomography (CT) showed frank pneumomediastinum and heterogeneous pleural effusion. He was subsequently referred to us in view of suspected Boerhaave’s syndrome and clinical worsening. In view of hemodynamic instability with uncontrolled sepsis, he was planned for surgery. Esophageal perforation repair operation and jejunostomy was performed for him. The postoperative period was uneventful, and he was discharged.Case two: A 62-year-old man was admitted to the emergency department with thoracic dull pain and chest distress that started after he had been vomiting several hours before presentation. On physical examination, he presented rough bronchovesicular breathing sound, and crepitant rales in lungs prompting subcutaneous emphysema. Chest CT scan showed pneumomediastinum and large left-sided pleural effusion. Esophagus fistula was confirmed by contrast esophagography. Therefore, spontaneous esophageal perforation was suspected. Then, we performed thoracotomy to repair the esophageal tear as well as to debride and irrigate the left pleural space. His vital signs remained stable intraoperatively, and his postoperative periods were uneventful with no leakage or stricture. Case three: The patient was a 69-year old male presenting with a severe retrosternal and upper abdominal pain followed an episode of forceful vomiting. At admission, he was diaphoretic and in respiratory distress. Physical examination revealed extensive cervical and thoracic subcutaneous emphysema but was otherwise unremarkable. A thoracic CT scan revealed a rupture in the left distal part of the oesophagus, a pneumomediastinum and left-sided pleural effusions. Conservative treatment, with cessation of oral intake, nasogastric suction, administration of intravenous fluids and parenteral nutrition, intravenous broad-spectrum anti-biotics, proton pump inhibitors and drainage of the pleural effusion by left-sided thoracostomy, failed to improve disease conditions. Open thoracic surgery was performed with debridement and drainage of the mediastinum and the pleural cavity, after which he made a slow but full recovery.CONCLUSIONS: We highlight that early diagnosis and appropriate surgical treatment are essential for optimum outcome in patients with esophageal rupture. We emphasize the importance of critical care support, particularly in the early stages of management.