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Boerhaave syndrome

Dr Garth Kruger and Radswiki et al.

Boerhaave syndrome refers to an oesophageal rupture secondary to forceful vomiting. Originally described in 1724 by Hermann Boerhaave, a Dutch physician/botanist. The syndrome was described after the case of a Dutch admiral Baron Jan von Wassenaer who died of the condition.

Epidemiology

It tends to be more prevalent in males. The estimated incidence is at ~ 1:6000 patients.

Clinical presentation

They are often associated with the clinical triad of vomiting, chest pain and subcutaneous emphysema (also called Mackler's triad). This condition was universally fatal before the age of surgery.

Pathology

It is thought occur due to a forceful ejection of gastric contents in an unrelaxed oesophagus against a closed glottis. The tears are vertically oriented, 1 - 4 cm's in length. Approximately 90% occur along the left posterolateral wall (left diapgragmatic crus) of the distal oesophagus.

Radiographic features

Plain film - chest radiograph

Imaging findings on plain film are often non specific and may include a pneumomediastinum or a pleural effusion.

Other signs include

V sign of Naclerio : a focal, sharply marginated region of paraspinal radiolucency in on the left side immediately above the diaphragm ³.

Fluoroscopy - contrast swallow

Upto 10% of patients may have a false negative result ³. May directly demonstrate contrast medium leakage often at a supra-diaphragmatic level.

CT

Features reported on unenhanced CT scans include the presence intramural haematoma with a typical localisation and periesophageal air collections indicating esophageal perforation ². Post contrast CT imaging may show direct contrast leakage / tracts and oesphageal wall thickening.

Other reported findings includes