A 60 year old man presents with a history of vomiting followed by the sudden onset of chest pain a few hours ago. On examination he has surgical emphysema over his neck and chest and evidence of a left pleural effusion.
Discuss your management of this patient.
Check ABCs and resuscitate if necessary
More extensive history and examination to look for other causes of surgical emphysema (eg CVC, barotrauma, pneumothorax), chest pain (eg pneumothorax, pulmonary embolus, musculoskeletal) and pleural effusion.
Look for signs of sepsis, shock and hypoxia.
Admit to highly monitored area in view of high risk of rapid clinical deterioration. NBM
Contrast CT abdo chest and neck / gastrograffin swallow (avoid barium) CXR: pleural effusion, ± pneumomediastinum, ± pneumothorax
Pleural fluid: presence of food particles, pH<6 and high amylase concentration indicative of oesophageal rupture but amylase may be high in pancreatitis.
Culture of pleural fluid Blood culture oesophagoscopy
Broad spectrum antibiotics including anaerobic cover plus antifungals
Early (within 24 hr) thoracotomy and repair or endoscopic placement of stent depending on whether patient shows signs of sepsis. Surgery preferred for septic patients, conservative if contained perforation.
Why, this is a wonderful question on Boerhaave's syndrome. "Discuss your management for the patient with oesophageal perforation".
Curci, JOSEPH J., and MARC J. Horman. "Boerhaave's syndrome: The importance of early diagnosis and treatment." Annals of surgery 183.4 (1976): 401.
Teh, Elaine, et al. "Boerhaave's syndrome: a review of management and outcome." Interactive cardiovascular and thoracic surgery 6.5 (2007): 640-643.
Skinner, David B., Alex G. Little, and Tom R. DeMeester. "Management of esophageal perforation." The American Journal of Surgery 139.6 (1980): 760-764.