Eric O. Then, MD1, Michell Lopez, MD1, Andrew Ofosu, MD2, Vijay Gayam, MD3, Vijay S. Are, MD4, Vinaya Gaduputi, MD, FACG5
1St. Barnabas Hospital, Bronx, NY; 2Brooklyn Hospital Center, Brooklyn, NY; 3Interfaith Medical Center, Brooklyn, NY; 4Stormont Vail Health System, Topeka, KS; 5SBH Health System, Bronx, NY
Introduction: Boerhaave’s syndrome (BS) is a rare, life-threatening entity that is defined as spontaneous esophageal rupture occurring after forceful vomiting. Classically treatment of BS has consisted of a surgical approach. Here we present a rare case of BS that was successfully treated through endoscopic measures.
Case Description/Methods: Patient is a 65 year old male with a medical history of chronic obstructive pulmonary disease who presented the emergency department with chest pain, shortness of breath and productive cough after an episode of retching 2 days prior. Notable workup in the emergency department included a chest x-ray which showed left lower lobe pneumonia, pneumothorax, and a left pleural effusion. A chest tube was then placed and a computed tomography angiography of the chest was also done. This showed pneumomediastinum with air around the mid to distal esophagus. A barium esophagram was subsequently done which showed contrast leak at the distal esophagus. An upper endoscopy was then performed and showed a large linear perforation near the gastroesophageal junction. This was closed with 2 over the scope clips in addition to placement of an overlapping partially covered stent. In order to ensure complete closure an esophagram was done with radioisotope. This showed complete closure of the perforation, with no evidence of leakage of the radiotracer. After the procedure the patient was able to tolerate oral feedings with no clinical sequelae. During his hospital stay the patient completed treatment with antibiotics, his chest tube was successfully removed and he was subsequently discharged home.
Discussion: Boerhaave’s syndrome is a lethal pathology that carries a high mortality rate. It mostly presents on the left posterolateral wall of the esophagus and occurs after forceful vomiting. Symptoms are non-specific and include vomiting, chest pain, dyspnea, and subcutaneous emphysema. Diagnosis of BS can be achieved through endoscopy, which allows direct visualization of the esophageal tear. Imaging studies such as barium swallow and CT scan may also be useful. These will show extravasation of contrast and pneumomediastinum respectively. Surgical repair is currently the treatment of choice in BS. Present day, endoscopic measures are challenging this consensus. More recently cases of BS have been successfully treated with the use of endoscopic suturing with esophageal stent placement. Our case was successfully treated by using 2 over the scope (OTS) clips and placement of an esophageal stent.
Citation: Eric O. Then, MD; Michell Lopez, MD; Andrew Ofosu, MD; Vijay Gayam, MD; Vijay S. Are, MD; Vinaya Gaduputi, MD, FACG. P0327 - SUCCESSFUL ENDOSCOPIC REPAIR OF BOERHAAVE’S SYNDROME: CHANGING THE NARRATIVE. Program No. P0327. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.