1. Boerhaave’s Syndrome "Spontaneous" esophageal rupture was described by Boerhaave in 1724. –Dutch admiral Baron John von Wassenauer overindulged on roast duck and wine, subsequently vomited/died –Autopsy revealed gastric contents in pleural space –at the time surgery was considered “a fools venture”

2. Herman Boerhaave 1668-1738 Dutch physician, botanist, chemist, medical educator, philosopher –self taught medicine –attended dissections but not lectures –married daughter of a rich merchant –did lectures for $ –treated rich and famous –insisted on autopsies –bedside teaching –did consults by mail –Never had a bad hair day

3. Boerhaave’s Syndrome Classic triad –vomiting, –excruciating chest pain –subcutaneous emphysema

7. CXR Left pleural effusion/ left hydropneumothorax in 12 to 24 hours. Pulmonary infiltrates SubQ air Widened mediastinum

8. Boerhaave’s Syndrome Anatomy –perf of esophagus -> mediastinum –negative pressure promotes soilage –90% tears along the left, posterolateral wall of the distal esophagus –role of esoph. disease is ? Etiology –retching against a closed glottis also laughing, childbirth, sz, trauma, heavy lifting most common cause upper endoscopy (~60%)

9. Causes Endoscopy (~60%) Dilations NG tubes Neck/abd Surgery Post emetic Infection Blunt trauma Caustics Foreign body Esoph disease

10. Boerhaave’s Syndrome Clinical features -may be delayed! Pain, (pleuritic, back, chest, abd) Dyspnea Subq Air/ mediastinal air Hamman’s crunch (systolic) Vomiting Dysphagia Change in voice Sepsis

11. Boerhaave’s Syndrome Treatment –ABCs –NPO –Antibiotics/fluids –Consultation Outcome –survival 65-90% –poor survival w/ delayed dx >48hrs

12. Boerhaave’s Syndrome Diagnosis –often difficult –1/3 presentations are atypical –Differential dx Spont. Mediastinum Thoracic Aortic Aneurysm PE PUD Pancreatitis Mesentaric ischemia

13. Follow up Pt underwent thoracotomy, repair Episode of lidocaine toxicity in the ICU Discharged home