Justina Palubinskienė¹, Vaiva Gudžiūnaitė¹, Ieva Balčiūnaitė¹

¹Lithuanian University of Health Sciences, Medical Academy, Faculty of Medicine

Abstract

Background. Boerhaave’s syndrome is a rare pathology, infamous for its high mortality. The main characteristic of this disease is a spontaneous full-thickness tear of the esophageal wall due to a sudden increase in intraluminal pressure. Mackler’s triad, the classic presentation of this syndrome, is constituted of chest pain, vomiting, and subcutaneous emphysema. Various other symptoms often lead to differentiation between acute myocardial infarction, pneumothorax, pulmonary embolism, aortic dissection, and other conditions. A chest x-ray is a primary test, as pathological changes are observed in close to 90% of cases. Boerhaave’s syndrome may be treated conservatively, endoscopically, or by surgery. Aim: to review the etiology, epidemiology, mechanisms of development, manifestation, diagnosis and treatment of Boerhaave’s syndrome. Methods. We searched for scientific literature in the Pubmed database. Eligible articles were selected using keyword analysis of the literature. 158 publications on Boerhaave syndrome have been analyzed. Results: a review of the literature revealed that Boerhaave’s syndrome is most commonly caused by vomiting in middle-aged men after consuming too much food or alcohol. According to literature reviewed, it is a sudden increase in pressure in the esophagus that causes a longitudinal rupture of its wall. Studies report vomiting, chest pain and dyspnea being the most frequent symptoms. Targeted clinical examination and selection of appropriate diagnostic methods are important for diagnosis, the most specific test being chest and mediastinal computed tomography scan. This pathology may be treated conservatively, but most authors recommend surgical treatment if the patient’s general condition and the nature of the lesion allow it. Discussion. Although the most common cause of Boerhaave’s syndrome has been identified as severe vomiting, the exact mechanism of rupture remains uncertain despite the efforts of various researchers. This pathology, due to its rarity and variety of initial symptoms, can mislead physicians and delay diagnosis. Early diagnosis (within 24 hours) is important as a determinant of a lower risk of complications and mortality. The tactics of surgical treatment also depend on it – in case of delayed diagnosis, radical surgery is chosen more frequently. Unfortunately, due to the relatively small number of patients and studies, there is not yet a standard treatment protocol for Boerhaave’s syndrome. Conclusions. Boerhaave’s syndrome is a rare pathology, most commonly caused by vomiting in the presence of excessive food and alcohol consumption. If suspected, a chest radiograph, contrast esophageal examination, CT are usually performed, endoscopy and other methods being less frequent. A similar tactic for diagnostics is reported amongst many authors. Meanwhile, treatment recommendations and outcomes vary significantly across studies and there is no consensus yet. Further research is needed to determine the optimal treatment tactics.

Keywords: Boerhaave’s syndrome, spontaneous esophageal rupture, esophageal perforation.