A Conservative and Multidisciplinary Approach to Boerhaave Syndrome: A Case Report

TL;DR

This case report describes a successful conservative treatment of a rare esophageal rupture in a 62-year-old man, avoiding surgery and leading to full recovery.

Contribution

The paper highlights a non-surgical, multidisciplinary approach to managing Boerhaave syndrome in a stable patient.

Findings

Conservative treatment with endoscopic interventions led to successful recovery in a stable patient with Boerhaave syndrome.

Delayed diagnosis and treatment are major causes of high mortality in this condition.

Non-surgical management can be effective when the patient is hemodynamically stable.

Abstract

Boerhaave’s syndrome is a life-threatening spontaneous esophageal rupture, usually in its distal part. It generally develops after situations that suddenly increase the intraesophageal pressure, such as, during or after persistent vomiting. Despite it being a rare condition in clinical practice, it has a high mortality rate (18-39%). Treatment can be approached conservatively, endoscopically, or surgically. The more invasive the treatment, the worse the prognosis.

This paper presents a healthy 62-year-old man who resorted to the emergency department complaining of lower back and left scapular pain, after two non-bilious episodes of vomiting. There was no history of any trauma, vigorous physical exercise or previous similar episodes. He was alert, hemodynamically stable, and without any airway compromise or respiratory distress. At the physical exam, non-painful subcutaneous crepitations were palpable in the left cervical region without palpable masses. Chest examination finds reduced air entry on the left pulmonary base. Hence, Boerhaave’s syndrome was suspected. CT scan revealed a pneumomediastinum and a left pulmonary collection. Oxygen therapy, blood cultures, empirical antibiotic therapy, and thoracic tube drainage were performed. The upper digestive endoscopy revealed the perforation in the distal esophagus, and an over-the-scope clip, a covered endoprosthesis and nasojejunal tube feeding were placed.

The patient was admitted to the Intermediate Care Unit for stabilization. He was discharged home on the 33rd day and remains well at two months of follow-up.

Delayed diagnosis and treatment are the principal causes of high mortality in Boerhaave’s syndrome. There is no standard treatment option. In this case report, given the patient’s stable clinical condition, the authors used a non-surgical conservative treatment, allowing for a delayed esophageal repair.

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