Delayed presentation of Boerhaave's syndrome.

To cite: Atie M, Dunn G, Falk GL. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2016217391 DESCRIPTION A 45-year-old, cognitively impaired, morbidly super obese male patient is described with a delayed presentation of Boerhaave’s syndrome. The patient had been mistakenly treated elsewhere for an empyema of the left thorax. The primary diagnosis had been based on a chest X-ray revealing hydropneumothorax and a thoracocentesis that delivered pus. The patient was transferred to our tertiary care unit, 5 days after initial presentation, following deterioration of his condition. The patient was in multiorgan failure requiring highdose inotropes and mechanical ventilation. CT scan of the chest, abdomen and pelvis revealed a defect in the mid-oesophageal wall (figure 1: black arrow=defect in oesophageal wall) with extravasation of nasogastric tube administered contrast into the left chest cavity (figures 1 and 2: C=contrast in pleural cavity). The left lung was severely collapsed, and intrapleural space food was present (figures 1 and 2: C=contrast in pleural cavity, L=lung and D=food debris in pleural space). The patient was unstable for surgery. Endoscopy was performed in ICU, and the nasogastric tube tip was positioned at the level of the defect for continuous irrigation. Two large radiological chest drains were inserted. This management stabilised the patient’s condition. Thoracotomy, decortication, T-tube oesophagostomy through the defect, appropriate drainage, tracheostomy and feeding jejunostomy were performed. Contrast study 8 weeks later did not show any leak. All tubes were removed. The patient was discharged home on soft diet. Boerhaave’s syndrome is associated with high mortality and morbidity. Prompt diagnosis and assessment with soluble contrast swallow coupled with endoscopy are the established standard. We prefer CT scan of the thorax, abdomen and pelvis with on-table NG administered soluble contrast, rather than swallow, for initial diagnosis. Besides diagnosis of the rupture, CT allows assessment of the extent of pleural, mediastinal and abdominal contaminations. CT also directs the performance of interventional radiology allowing precise allocations of drains and punctures. Delayed presentation and time to initiate management are associated with a mortality rate that exceeds 80%. A treatment algorithm was published in 2009, based on current level 4 evidence, indicating that all septic patients should be treated surgically, early presentations without sepsis endoscopically and delayed presentations without sepsis conservatively. Griffin et al suggest that conservative management is specifically reserved for delayed presentations with contained, wide-necked perforations without sepsis and for those who demonstrate tolerance to pleural contamination amenable to radiological drainage. Endoscopic treatment, on the other hand, is associated with a significant complication rate. No provision has been made in published treatment algorithms for patients with delayed presentations who are septic and unfit for surgical intervention. Figure 3 displays our proposed treatment algorithm for patients with Boerhaave’s syndrome. The flow chart incorporates the management plan for the delayed unstable patient. Our case report demonstrates that aggressive surgical management remains the main stay of treatment in the latter group of patients once their condition has been stabilised.