Boerhaave’s syndrome secondary to colonic interposition graft perforation

Abstract

Dear Editor: Spontaneous esophageal perforation (Boerhaave's syndrome) remains a difficult diagnostic and management problem. Boerhaave first reported a syndrome in 1724 on Baron Wassenaar, Grand Admiral of the Dutch fleet, a glutton who practiced the Roman habit of autoemesis. Mackler described the triad classical presentation of vomiting, lower thoracic pain and subcutaneous emphysema following a large meal. However, atypical presentations can occur. The diagnosis carries a significant morbidity and mortality of up to 30%. Late or misdiagnosis is common in 50% of cases due to the rarity of the condition and its nonspecific presentation. Management is controversial since the treatment can be surgical or non-surgical. The indications vary according to the site, size of lesion and associated conditions: time elapsed between injury and presentation, functional state of oesophagus, degree of mediastinal contamination and preference of the team. To our knowledge, this is the first case in the literature of perforation in a patient with colonic interposition repair of the oesophagus as a child. A 50-year-old patient presented to a local hospital with chest pain, epigastric pain and dysponea. The pain had developed after vomiting following a meal. Past medical history included an operation on the oesophagus carried out through a left thoracotomy at age 2 and 7, respectively—the nature of which was not known to the patient or her family. Co-morbidities included long-standing gastro-esophageal reflux disease and epilepsy. Remaining history was unremarkable. On examination the patient was systemically well with no initial evidence of sepsis. There was tenderness over the right upper quadrant and epigastium. The initial diagnosis was acute cholecystitis, with a differential of right-sided pneumonia. Chest X-ray showed a small left-sided pleural effusion. Due to a worsening type I respiratory failure, a chest and abdominal CAT scan was organized. This demonstrated mediastinal air, fluid around the distal oesophagus, air under the diaphragm and bilateral pleural effusions. The oesophagus was dilated and there was intrathoracic gastric herniation. The findings were suggestive of a ruptured oesophagus. Gastrograffin contrast study confirmed an obvious leak on the right and a chest drain was inserted. The patient was commenced on IV antibiotics and transferred to a tertiary upper GI surgical centre where she was promptly taken to theatre. The patient underwent an upper midline laparotomy; there were dense adhesions in the upper abdomen and the stomach had herniated into the thoracic cavity. On repositioning the stomach into the abdominal cavity, it was evident that there was a colonic segment interposed between the stomach and the oesophagus. The perforation was visualized at gastroscopy to be in the colonic segment at 30 cm ab oral. This was not amiable for primary repair R. Attia :M. Scarci Department of Cardiothoracic Surgery, Guy’s and St Thomas’ Hospital NHS Foundation Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK

DOI: 10.1007/s00384-010-0923-8

Cite this paper

@article{Attia2010BoerhaavesSS, title={Boerhaave’s syndrome secondary to colonic interposition graft perforation}, author={Rizwan Q Attia and Ashish Rohatgi and Marco Scarci and Ahmad Hamouda and Abrie J. Botha}, journal={International Journal of Colorectal Disease}, year={2010}, volume={25}, pages={1147-1148} }