Boerhaave's Syndrome: Causes, Symptoms, Diagnosis and Treatment

Boerhaave's syndrome is characterized by an esophageal rupture brought on by extreme stress. This occurs when there is extreme strain or acute vomiting that tears the esophageal wall apart. Physicians refer to this as "effort rupture" or "spontaneous rupture" to differentiate it from ruptures resulting from a genuine esophageal lesion.

An esophageal tear, or Mallory Weiss tear, is a tear in the mucosal lining. Similar to Boerhaave's syndrome, it also happens during severe vomiting or straining, and both are linked to excessive alcohol consumption. Although it doesn't tear through the esophagus, a Mallory Weiss tear will make you throw up blood. In contrast, the esophageal wall is ruptured across its whole thickness in Boerhaave's syndrome. 

Another name for this is a transmural rip. It may be necessary to heal a transmural tear immediately because doing so could mean the difference between life and death.

Causes Of Boerhaave's syndrome

• Irritation in your chest cavity
• Edema
• A pus accumulation in your chest cavity, known as an empyema.
• Trapped air in the tissues in your chest cavity or under your skin.
• A collection of fluid, or pleural effusion, in the lining of your chest cavity.
• ARDS, or acute respiratory distress syndrome
• Shock, septicemia, and sepsis.

Two factors seem to be involved. The first is an internal build-up of pressure in your esophagus caused by intense effort or strain. An accumulation of negative pressure outside the esophagus happens in the other case, which is caused by the cricopharyngeus muscle, which serves as the upper esophageal sphincter, failing to relax in response to pressure.

In patients with Boerhaave's syndrome, forceful or frequent vomiting is the most common source of strain. The following are possible causes: giving birth, having convulsions, lifting weights, and consuming anything caustic or acidic.

Normally, in order to release the internal pressure, the cricopharyngeus muscle would have relaxed in response to nerve signals. That neuromuscular synchronization is, however, disrupted in Boerhaave's condition for an unknown reason.

Also Read: Subarachnoid Haemorrhage: Causes, Symptoms, Risk Factors, Diagnosis and Treatment

Symptoms Of Boerhaave's syndrome

• Sudden, severe chest pain.
• Nausea and vomiting.
• Discomfort or coughing during swallowing.
• Rapid, shallow breathing.
• Swelling of the tissues in the chest cavity that are filled with liquid or air.
• A firm, rigid abdomen.
• Sweating and fever as signs of sickness

Diagnosis Of  Boerhaave Syndrome

Diagnosing Boerhaave's condition can be difficult, thus early detection is essential. It is easier to diagnose when the classic Mackler trio of symptoms is present. These include sudden, intense chest discomfort, acute or frequent vomiting, and subcutaneous emphysema, a condition in which air becomes trapped in the tissues just beneath the skin. The last symptom is especially suggestive of an esophageal rupture.

Not all cases, nevertheless, display the common symptoms. The rupture may occur in an uncommon location, such as your neck or clavicles, resulting in pain in an uncommon location. It may be caused by fewer common things than vomiting, or it may have peculiar side effects. A standard chest X-ray might reveal some details, but it will require a more sensitive imaging test to diagnose the condition.

Esophagram

An esophagram, or fluoroscopic X-ray with contrast dye, is usually the first step when your doctor suspects Boerhaave's syndrome because of its high degree of precision, quickness, and noninvasiveness. For this test, you will need to swallow a solution containing a water-soluble contrast dye, which will increase the visibility of your esophagus on the X-ray. If you have a tear, they can see where the contrast coloring seeps out.

CT scan.

A CT scan is an alternative option if the esophagram isn't functioning for you or if your doctor needs a closer look at the surrounding organs. Although it is unable to locate the tear precisely, it can identify even small amounts of air leakage from your esophagus and contrast dye leakage in the surrounding tissues. It’s also used to locate pockets of leaked fluids in your chest and abdominal cavities that will need to be drained.

Also Read: Mammary Duct Ectasia: Causes, Symptoms, Diagnosis, Treatment and Complications

Treatment Of Boerhaave Syndrome

Treatment proceeds as follows:

• IV fluid: The majority of patients require rapid IV fluid resuscitation because of total volume loss.
• Antibiotics: To manage infection, a wide range of intravenous antibiotics will be administered.
• Surgical Consultation: For most people, surgery is the standard of care. Certain minor, confined tears might be better treated with endoscopy rather than monitoring and IV antibiotics. Healthcare professionals will nevertheless want to have a surgical backup plan in these situations.
• Surgery: The rupture should ideally be fixed right away within a day. Your surgeon can perform minimally invasive surgery using a technique called video-assisted thoracoscopic surgery (VATS), depending on your situation. In certain emergencies, an open thoracotomy may be necessary to provide rapid and comprehensive access to your full thoracic cavity.
• Debris removal and clearing: It is necessary to remove any infected or necrotic (dead) tissue from the cavity and to clean and empty any contaminated fluid accumulations inside in addition to patching the actual tear. Under certain extreme conditions, this may necessitate the removal of a section of your esophagus.
• Advanced administration: If surgery cannot be completed in the 24 hours that follow the rupture, direct repair may not work. It could be the case that the wound's edges are beginning to rip or constrict. Your esophagus may need to be removed whole or in part by your surgeon in this case. If a replacement esophagus is required, it can be done after six weeks.
• Alternative eating plan: Since your esophagus will not be functional during the healing process, you will require an alternative way of feeding. This might be by tube or by vein.

Also Read: Retrograde Ejaculation: Causes, Symptoms, Risk Factors, Diagnosis, Treatment, Prevention and Complications

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