Introduction
Boerhaave syndrome is a medical term for a tear in the oesophagus named after a Dutch physician. This rarely occurring disease occurs spontaneously. It causes a tear in all the layers of the esophageal wall, so that finally there is an opening in the chest cavity.
The spontaneous rupture usually occurs directly above the diaphragm. This position of the injury is called supradiaphragmatic. In most cases, the cause is excessive pressure in the abdominal cavity.
During vomiting or strong coughing attacks, a high intra-abdominal pressure builds up, which can be so strong that the tissue of the oesophagus cannot withstand this increased pressure. The prerequisite for the injury is often an existing pre-damage to the muscles of the oesophagus. The musculature can be affected by various factors such as an incorrect diet or massive alcohol abuse.
Boerhaave syndrome is also frequently seen in patients with eating disorders. For example, buerhaave, in which patients often vomit specifically, is a typical damage to the tissue layers. If the oesophagus ruptures, the patient is at increased risk of developing an inflammation in the thorax or even an overarching infection known as sepsis.
Symptoms
Boerhaave syndrome occurs suddenly and with different symptoms. Typical for this disease is a sudden onset of pain behind the breastbone (sternum). This symptomatology, known as retrosternal pain, is also called pain of destruction.
The complaints often put the patient in a very anxious or even panicky situation, as many patients are also unable to breathe properly. They suffer from shortness of breath (dyspnoea). Further symptoms can be vomiting with blood admixtures.
This is then called haematoemesis. Occasionally a skin emphysema also occurs. This is an abnormal accumulation of air in the subcutis, which can be detected by deformity of the skin.
While palpating the skin, a slight crackling sound can be heard, which sounds like walking on snow. The injury to the oesophagus is in some cases an acute and possibly threatening situation for the patient, as in some cases shock can also occur. This is accompanied by circulatory failure and a drop in blood pressure and should be treated immediately.
Therapy
The Boerhaave syndrome represents a dangerous and also acutely life-threatening situation for the patient. Immediate intensive medical treatment is required. An operation is necessary to close the hole in the esophagus.
This defect is covered by opening the thorax (thoracotomy) or the abdomen (laparotomy). This is a major operation, which is why careful intensive medical monitoring is carried out afterwards. The injury can be sutured or covered with the patient’s own tissue.
Because the defect in the oesophagus allows stomach contents to flow into the chest area, there is a risk of the chest becoming inflamed. This dangerous complication is called sepsis or mediastinitis. In order to provide the patient with additional protection against this, he or she is given a broad-spectrum antibiotic as an infusion.
The patient also receives painkillers. After the operation, the patient is first given parenteral nutrition. This means that the patient receives food in the form of infusions via an access point in the vein or via the stomach tube.
This is to prevent the suture from tearing again and the wound can heal at rest for the time being. Later, a slow build-up of food takes place. The treatment should be carried out as soon as possible after the syndrome has occurred, otherwise the patients usually die of the complications a short time later.
