Boerhaave

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Boerhaaves Syndrome

• "Spontaneous" esophageal rupture was described by
  Boerhaave in 1724.
• Dutch admiral Baron John von Wassenauer
  overindulged on roast duck and wine, subsequently
  vomited/died
• Autopsy revealed gastric contents in pleural
  space
• at the time surgery was considered a fools
  venture

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Herman Boerhaave1668-1738

• Dutch physician, botanist, chemist, medical
  educator, philosopher
• self taught medicine
• attended dissections but not lectures
• married daughter of a rich merchant
• did lectures for
• treated rich and famous
• insisted on autopsies
• bedside teaching
• did consults by mail
• Never had a bad hair day

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Boerhaaves Syndrome

• Classic triad
• vomiting,
• excruciating chest pain
• subcutaneous emphysema

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CXR

• Left pleural effusion/ left hydropneumothorax in
  12 to 24 hours.
• Pulmonary infiltrates
• SubQ air
• Widened mediastinum

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Boerhaaves Syndrome

• Anatomy
• perf of esophagus -gt mediastinum
• negative pressure promotes soilage
• 90 tears along the left, posterolateral wall of
  the distal esophagus
• role of esoph. disease is ?
• Etiology
• retching against a closed glottis
• also laughing, childbirth, sz, trauma, heavy
  lifting
• most common cause upper endoscopy (60)

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Causes

• Endoscopy (60)
• Dilations
• NG tubes
• Neck/abd Surgery
• Post emetic
• Infection

• Blunt trauma
• Caustics
• Foreign body
• Esoph disease

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Boerhaaves Syndrome Clinical features -may be
delayed!

• Pain, (pleuritic, back, chest, abd)
• Dyspnea
• Subq Air/ mediastinal air
• Hammans crunch (systolic)

• Vomiting
• Dysphagia
• Change in voice
• Sepsis

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Boerhaaves Syndrome

• Treatment
• ABCs
• NPO
• Antibiotics/fluids
• Consultation
• Outcome
• survival 65-90
• poor survival w/ delayed dx gt48hrs

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Boerhaaves Syndrome

• Diagnosis
• often difficult
• 1/3 presentations are atypical
• Differential dx
• Spont. Mediastinum
• Thoracic Aortic Aneurysm
• PE
• PUD
• Pancreatitis
• Mesentaric ischemia

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Follow up

• Pt underwent thoracotomy, repair
• Episode of lidocaine toxicity in the ICU
• Discharged home