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.

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College Answer

Initial management
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

Investigations
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

Definitive treatment
Broad spectrum antibiotics including anaerobic cover plus antifungals
Pleural drainage
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.

Discussion

Why, this is a wonderful question on Boerhaave's syndrome. "Discuss your management for the patient with oesophageal perforation".

Immediate management

  • Attention to ABCs and correction of immediately identified lifethreatening features
  • Detailed history and thorough physical examination
  • Assessment of airway patency and intubation as needed
  • Maintenance of normoxia with supplemental oxygen
  • Maintenance of normotension with fluid resuscitation and vasopressors as needed
  • Analgesia and sedation
  • Attention to broad-spectrum antibiotic cover, including antifungal agents

Investigations:

  • CXR looking for pneumomediastinum
  • CT chest with contrast
  • Gastrograffin swallow (not barium)
  • Intercostal catheter to drain pleural effusion and analyse it, looking for acidity (suggestive of gastric contents) and food particles

Specific Management

  • Thoracoscopic or open surgical management;
  • alternatively, endoscopic stent placeemnt
  • alternatively, conservative antibiotic-based management and supportive care in ICU

References

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.