Boerhaave’s syndrome or spontaneous perforation of the oesophagus

Abstract

Spontaneous perforation of the oesophagus, also called Boerhaave’s syndrome, is a barogenic rupture caused by a sudden rise in intraluminal pressure, usually in the distal oesophagus. Early diagnosis of spontaneous oesophageal perforation is critical to the survival of the patient. Sudden and very intense chest or epigastric pain after an abrupt increase of oesophageal intraluminal pressure is the most characteristic clinical symptom and should raise suspicion for Boerhaave’s syndrome. Plain radiographs demonstrate the presence of free air in the mediastinum, subcutaneous emphysema or air subdiaphragmatically, as well as pleural effusions. Upper gastrointestinal series reveal leakage of the contrast and confirms the location of the perforation. Similarly, chest computed tomography demonstrates the presence of an air-fluid level, pneumomediastinum and pleural effusions and, more importantly, the complications related to oesophageal perforation. Oesophageal perforation is associated with a high mortality rate, suggested to be approximately 2% for every hour after initial presentation. More specifically, diagnosis and intervention within the first 12 hours results in 80-90% survival, which falls to 70-75% between 12-24 hours; after 24 hours, survival decreases to less than 50%, and after 48 hours to less than 10%. Operative treatment of Boerhaave’s syndrome mainly includes a complete debridement and lavage of infected and necrotic tissues with wide drainage of the mediastinum and pleural cavities and either primary oesophageal repair and reinforcement (if diagnosed early) or T-tube diversion or resection (if diagnosis is delayed). Early confirmation of the diagnosis is very important because it allows earlier support of the critically ill patient and prompt operative intervention when necessary. Eventful outcome of patients is related to these