Spontaneous esophageal rupture (Boerhaave syndrome) with complications in a patient with advanced reflux esophagitis with no evidence of contrast agent leakage

Introduction: Boerhaave syndrome involves spontaneous rupture of the esophagus after forceful vomiting in alcoholics.

Case report: A 42-year-old male alcoholic was admitted to our ward on 11.26.07. After heavy alcohol intake, the patient vomited coffee-ground like matter and experienced bilaterally thoracic pain. The chest- and abdominal X-ray were negative. During gastroscopy, at the esophageal entrance we observed a fibrinous layer, which at 25cm assumed a circular shape partly detached from the esophagus wall. It continued to the level of the cardia with a hiatic hernia visible at 41–44cm. The next day, above the left diaphragm a dull percussion noise was detected with pleural noise. The chest X-ray and the chest- and abdominal CT showed mediastinal, retroperitoneal and subcutaneous emphysema with enclosed air content and some fluid in the mediastinum. There was no leakage of the contrast agent during the gastrographin swallow. In the distal paraesophageal area there was a semicircle of foam-like structures with the density of air. The patient was admitted to the surgery ward where the mediastinal abscesses were drained through the hiatus, a thoracic and a cervical incision. A jejunostomy was performed to allow the feeding of the patient. Intraoperative esophageal perforation was not detected. On 01.04.08, the patient suffered total esophageal obstruction. Despite elevated doses of PPI therapy, restenosis occurred. The patient was admitted to our ward three times, and esophageal dilation was performed a total of 13 times using balloon catheters up to 16mm in diameter. Since the last treatment of the patient in May 2008 he remains symptom-free.

Conclusion: In alcoholics with advanced reflux esophagitis, we must consider the possibility of Boerhaave syndrome. The absence of contrast agent leakage, even when accompanied by typical X-ray and CT results, does not rule out earlier esophageal perforation. Timely, adequate treatment may result in full recovery even in cases with additional complications.