A case of boerhaave syndrome - challenges in diagnosis and treatment

Abstract

Introduction. Boerhaave syndrome is a rare yet dangerous condition and one of the most lethal diseases of the gastrointestinal tract marked by transmural esophageal perforation. It is often preceded by forceful vomiting. Early diagnosis and treatment is mandatory for the possibility of a good outcome. Boerhaave syndrome can be associated with Mackler’s triad: vomiting followed by severe chest pain and subcutaneous emphysema. Case statement. We present the case of a 41-year-old male patient, who presented to the hospital for chest pain, dyspnea, tachycardia, pain when swallowing and hoarse voice. The symptoms appeared after the patient forced himself to vomit after swallowing a candy that got stuck. The presumptive diagnoses were acute gastroduodenitis, laryngeal edema and intercostal neuralgia. Treatment with Analgin, Dimedrol was started. On the second day, the patient began to present subcutaneous emphysema. A fibrogastroduodenoscopy was performed and it revealed an esophageal perforation in the lower third and the patient was diagnosed with Boerhaave syndrome. Papaverine, Cefazolin, Pantoprazole, Clemastine and Maalox were added to the treatment scheme and the patient was transferred to the surgery department. Urgent surgery was performed on the third day with posterior mediastinal debridement and irrigation. Unfortunately the patient developed mediastinitis and is currently in ICU in critical condition with leukocytosis, fever, tachycardia and a high CRP. Discussions. In this case, the uncommon cause of esophageal perforation and the common symptoms for a wide range of diseases led to a delayed diagnosis and the patient developing mediastinitis. The late surgical treatment resulted in a bad prognosis. Conclusion. Boerhaave syndrome can be challenging to diagnose because of the lack of classic symptoms. The mortality rate can reach over 75% if the diagnosis is not made within the first 1224 hours and reaches 100% if left untreated. Despite the treatment, the late intervention led to a worse outcome. diseases of the gastrointestinal tract marked by transmur al esophageal perforation. It is often preceded by forceful vomiting. Early diagnosis and treatmen t is mandatory for the possibility of a good outcome. Boerhaave syndrome can be associated with M ackler’s triad: vomiting followed by severe chest pain and subcutaneous emphysema. Case statement. We present the case of a 41-year-old male patient, who pr esented to the hospital for chest pain, dyspnea, tachycardia, pain when swallowing a nd hoarse voice. The symptoms appeared after the patient forced himself to vomit after swa llowing a candy that got stuck. The presumptive diagnoses were acute gastroduodenitis, laryngeal e dema and intercostal neuralgia. Treatment with Analgin, Dimedrol was started. On the seco nd day, the patient began to present subcutaneous emphysema. A fibrogastroduodenoscopy was performed and it revealed an esophageal perforation in the lower third and the patient was diagnosed with Boerhaave syndrome. Papaverine, Cefazolin, Pantoprazole, Clemastine and Maa lox were added to the treatment scheme and the patient was transferred to the surgery department. Urgen t surgery was performed on the third day with posterior mediastinal debridement and irri gation. Unfortunately the patient developed mediastinitis and is currently in ICU in critica l condition with leukocytosis, fever, tachycardia and a high CRP. Discussions. In this case, the uncommon cause of esophageal perforati on and the common symptoms for a wide range of diseases led to a delayed dia gnosis and the patient developing mediastinitis. The late surgical treatment resulted in a bad prognosis. Conclusion. Boerhaave syndrome can be challenging to diagnose because of the lack of classic symptoms. The mortality rate can reach over 75% if the diagnosis is not made within the first 1224 hours and reaches 100% if left untreated. Despite the tre atment, the late intervention led to a worse outcome.