A 27-Year-Old Man With Hyperemesis and Hematemesis

Gerard J. Fitzmaurice, BSc, MBBCh BAO; Robin Brown, MD, FRCS; Mark E. O'Donnell, DSEM, MFSEM, MRCS; Fionnuala Mone, MBBCh BAO; Angela McGreevy, MBBCh BAO

Disclosures

June 27, 2017

Immediate medical management involves stabilizing the patient with IV fluid resuscitation, nasogastric suction, broad-spectrum antibiotics, and narcotic analgesics.[3]

Options for treatment of Boerhaave syndrome include conservative management or surgical intervention. Unfortunately, a delay between the onset of symptoms and presentation and diagnosis is typical.[2] Clinical features that support conservative therapy include an absence of clinical signs of infection; a contained perforation in the mediastinum and the visceral pleura, without penetration to another body cavity; and a perforation with the contrast medium draining back into the esophagus.

Some authors believe that if treatment is instituted more than 24 hours after the perforation, the mode of treatment does not influence the outcome and can therefore be conservative management, placement of a tube thoracostomy (drainage), repair, or diversion. Conservative management involves administration of IV fluids and broad-spectrum antibiotics, nasogastric suction, keeping the patient NPO, and early nutritional support (jejunostomy feeding is favored).[2,3]

Surgical intervention is favored when the diagnosis is made early (within the first 24 hours after perforation).[2,10] Surgical techniques used for treating esophageal rupture include the following:

  • Tube thoracostomy (drainage with a chest tube or operative drainage alone)

  • Primary repair

  • Primary repair with reinforcement (pleura, intercostal muscle, diaphragm, pericardial fat, pleural flap)

  • Diversion

  • Diversion and exclusion

  • Esophageal resection

  • Thoracoscopic repair

  • Esophageal stent

  • Endoscopic placement of fibrin sealant

Possible complications of surgical intervention include leaks, sepsis, respiratory failure, mediastinitis, shock, empyema formation, esophagotracheal/esophagobronchial fistula formation, and death.[3]

As previously stated, in Boerhaave syndrome the prognosis is directly related to the time to diagnosis and appropriate intervention. Intervention within 24 hours of symptoms has a survival rate of 75%; this rate drops to 35% with a 24-hour delay, then to 11%-25% if diagnosis and treatment are delayed by 48 hours.[3]

In this patient, immediate fluid resuscitation was initiated, with administration of IV cefuroxime and metronidazole. Because of the 20% false-negative rate of an initial esophagram, the study was repeated, and it again confirmed the original finding of no evidence of a leak.

The patient was treated conservatively with broad-spectrum IV antibiotics, kept NPO with nutritional feeding through a jejunostomy tube, and given adequate hydration through IV fluids (with urine output monitoring). He improved significantly; repeat CT of the chest demonstrated a normal mediastinum. After hospitalization for 10 days, he was discharged to home in good health.

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