S2046 Conservative Management in a Patient With Recurrent Boerhaave Syndrome

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Introduction: Boerhaave syndrome (BS) is rare and involves a full thickness tear of the esophagus. Nearly all cases require correction of the tear, either surgically or endoscopically. In rare cases when the patient has mild to no symptoms, no evidence of neoplastic tissue, and a swallow study showing no active leakage of contrast, conservative management can be attempted. Here we report a man with a history only notable for BS 9 months prior, who presented with another episode of BS. Case Description/Methods: A 30-year old man, with a past medical history of BS 9 months prior, managed conservatively at that time, and an abdominal stab wound 8 years ago, presented to the Emergency Department (ED) for 2 days of nausea, vomiting and decreased oral intake. Review of systems on presentation was notable only for sore throat and fatigue. His presenting vital signs were within normal limits and physical exam was notable only for a well healed abdominal surgical scar. Initial workup was remarkable for a creatinine of 2.0 and a chest x-ray that revealed subcutaneous emphysema overlying the neck and chest wall. A subsequent CT chest/abdomen/pelvis demonstrated extensive air tracking along the mediastinum, esophagus, bilateral neck and chest wall. A gastrografin swallow study showed no evidence of esophageal contrast extravasation. Cardiothoracic surgery and Gastroenterology both recommended conservative therapy. Throughout the hospital course, the patient remained hemodynamically stable and his creatinine returned to normal limits. The patient was kept NPO for 7 days, received IV pantoprazole twice a day, and a total of 7 days of piperacillin/tazobactam for broad spectrum antibiotic coverage. Given the duration of time he was kept NPO, total parenteral nutrition was administered. After 7 days, the patient was begun on a clear liquid diet and subsequently progressed to a regular diet over 24 hours. The patient was discharged on a 6 week course of omeprazole with a plan for an upper endoscopy 8 weeks later. Discussion: This is a rare case of recurrent BS managed conservatively with each episode. There is limited research published regarding conservative management of BS, which adds a layer of difficulty to medical decision making for patients such as these. Continuing to report and investigate conservatively managed BS cases would be greatly beneficial in assisting future providers in the management of BS.