Survival after Esophageal Rupture during the COVID Pandemic: The Evolution of a Mallory Weiss Tear to Boerhaave’s Syndrome

Kaczynski Re,Battista J,Rogers Eh,Amador-Jimenez J,Shakir H,Colaco R

doi:10.36502/2021/asjbccr.6224

Abstract

We present the case of a 42-year-old male cirrhotic chronic alcoholic who was admitted during the height of the COVID pandemic with a large right pleural effusion. Thorough investigation revealed a large right-sided distal esophageal rupture near the gastroesophageal junction and he was diagnosed with Mallory Weiss tear converted to Boerhaave’s syndrome. He successfully underwent endoscopic placement of a covered esophageal stent, but had a protracted recovery with presumed empyema continuing to require chest tube drainage. He eventually required surgical intervention with a right thoracotomy, decortication, and wash out. Our case provides an excellent example of the risk of distraction during a global pandemic secondary to nonspecific symptomatology being attributed to COVID-19 and significant critical care requirements leading to a significant delay in diagnosis of an esophageal rupture. However, our patient is also uniquely impressive when compared to similarly published cases of Mallory Weiss conversion to Boerhaave’s Syndrome given his survival with excellent clinical outcome leading to discharge home on oral diet despite his increased risk of morbidity based on his prolonged critical illness disease course.

Highlights

We present the case of a 42-year-old male cirrhotic chronic alcoholic who was admitted during the height of the COVID pandemic with a large right pleural effusion
Our case provides an excellent example of the risk of distraction during a global pandemic secondary to nonspecific symptomatology being attributed to COVID-19 and significant critical care requirements leading to a significant delay in diagnosis of an esophageal rupture
Our patient is uniquely impressive when compared to published cases of Mallory Weiss conversion to Boerhaave’s Syndrome given his survival with excellent clinical outcome leading to discharge home on oral diet despite his increased risk of morbidity based on his prolonged critical illness disease course

Summary

Introduction

We present the case of a 42-year-old male cirrhotic chronic alcoholic who was admitted during the height of the COVID pandemic with a large right pleural effusion. Thorough investigation revealed a large right-sided distal esophageal rupture near the gastroesophageal junction and he was diagnosed with Mallory Weiss tear converted to Boerhaave’s syndrome He successfully underwent endoscopic placement of a covered esophageal stent, but had a protracted recovery with presumed empyema continuing to require chest tube drainage. Our patient later returned to the ICU on an Ativan drip due to alcohol withdrawal which had progressed to delirium tremens His thoracostomy tube remained on suction but subsequent chest x-rays did not show improvement of the effusion despite changes in antibiotic regimen including antifungal coverage. Upon re-evaluation by Cardiothoracic surgery, Fig-2: AP chest x-ray demonstrating upsizing to two 28F thoracostomy tubes in right hemithorax His chest tube output was noted to be clear and foamy rather than purulent or straw-colored and raised concern for salivary contents as opposed to a traditional transudative effusion. Our patient has required another admission for pigtail thoracostomy drainage of pleural fluid collections and endoscopic re-positioning of the stent, but he has recovered well and is tolerating a regular diet without restrictions

Findings

Discussion

Conclusion