1746 A Surprising Case of Boerhaave's Syndrome Successfully Treated With a Single Hemostatic Clip

Abstract

INTRODUCTION: Boerhaave’s Syndrome (BS), defined as transmural esophageal perforation, is rare and associated with 35% mortality. Patients with BS can develop associated mediastinitis, sepsis, and septic shock. Patients require urgent management, usually with volume resuscitation, antibiotics, surgical intervention, or occasional endoscopic placement of a metallic stent. There are few reported cases demonstrating successful repair of esophageal perforation with hemostatic clips alone. We present a case of direct repair of BS with a single hemostatic clip. CASE DESCRIPTION/METHODS: A 44-year-old male presented to the ED for food impaction with subsequent development of large volume hematemesis. He was stable, with no sign of respiratory distress. However, given his persistent hematemesis, he was intubated for airway protection. Initial labs were remarkable for leukocytosis to 14.8 and hemoglobin of 18.4. A Mallory Weiss tear was expected, but his CT chest showed inflammation in the mediastinum associated with debris in the esophagus and esophageal wall thickening. His clinical picture and imaging were consistent with BS complicated by mediastinitis and esophagitis with superimposed esophageal perforation. He was given one dose of both Zosyn and a PPI and was taken for emergent EGD. Red blood and clots were seen throughout his esophagus, and a large non-bleeding tear with stigmata of recent bleeding was seen in the distal esophagus. One hemostatic clip was placed with successful resolution of the defect. He was then admitted to the medical ICU for further management. Over the next 24 hours, he developed melena and became tachycardic. His leukocytosis peaked at 21, and his hemoglobin gradually decreased to 8.9. Repeat CT chest was obtained due to worsening symptoms, but imaging showed that the esophageal clip was in place, and there was improvement in prior esophageal wall thickening, but there was a new small left pleural effusion. Cardiothoracic Surgery evaluated the patient and recommended an esophagram, which showed no evidence of esophageal contrast extravasation. He was successfully extubated and was discharged home the following day. DISCUSSION: BS is often a medical emergency requiring urgent intervention. Most cases are treated surgically with direct repair of the rupture via thoracotomy or laparotomy. Although there is a known role for endoscopic management using a metallic stent, there is an evolving role for treatment of more mild cases of BS with clip placement alone.