WORKUP	Section 5 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Lab Studies:

• Laboratory findings often are nonspecific.

• Patients may present with leukocytosis and a left shift.

• As many as 50% of patients have a hematocrit value that approaches 50%. This may be due to fluid loss into pleural spaces and tissues.

• Serum albumin is normal but may be low, while the globulin fraction may be normal or slightly elevated.

• Many patients present with a pleural effusion.

• Thoracentesis with examination of the pleural fluid can aid in diagnosis.

• Undigested food particles and gastric juices usually are found.

• If no gross particles are found, cytology can confirm or exclude their presence, but time is of the essence.

• The pH of the pleural fluid will be less than 6, and the amylase content will be elevated.

• Squamous cells from saliva may be found.

Imaging Studies:

• Upright chest radiograph

• This is useful in the initial diagnosis because 90% of patients reveal an abnormal finding after perforation.

• The most common finding is a unilateral effusion, usually on the left. This corresponds with the fact that most perforations occur in the left posterior aspect of the esophagus.

• Other findings may include pneumothorax, hydropneumothorax, pneumomediastinum, subcutaneous emphysema, or mediastinal widening.

• The V-sign of Naclerio has been described as a chest radiograph finding in as many as 20% of patients. This involves the presence of radiolucent streaks of air that dissect the fascial planes behind the heart to form the shape of the letter V. It is a fairly specific, although insensitive, radiographic sign of esophageal perforation.

• Overall, 10% of chest radiographs are normal. This can be at least partly explained by the delayed radiographic development of mediastinal and subcutaneous emphysema. These findings may take an hour or more after perforation to appear on the chest radiograph.

• Esophagram

• This helps confirm the diagnosis.

• It typically shows extravasation of contrast into the pleural cavity.

• The study outlines the length of the perforation and its location, which aids in the decision of whether to use a thoracic or abdominal surgical approach.

• Initially, use a water-soluble contrast, such as Gastrografin. It has 90% sensitivity.

• It may have false-negative results in up to 20% of patients.

• The use of barium in patients affected with Boerhaave syndrome has been associated with severe mediastinitis. This complication may contribute significantly to increased morbidity and mortality.

• If the contrast study is negative and the clinical index of suspicion remains high, placing the patient in the left and right lateral decubitus positions often is helpful. The use of barium would then be warranted.

• CT scan

• It can reveal decisive criteria for diagnosis.

• It is helpful in patients too ill to tolerate esophagrams.

• It localizes collections of fluid for surgical drainage.

• Visualization of adjacent structures is possible, which expands the differential diagnosis in patients with chest pain and vomiting.

• It can demonstrate periesophageal air tracks that are suggestive of perforation.

• CT scan may not precisely localize the site of perforation.

Procedures:

• Endoscopy is not commonly used to aid in diagnosis.

• It carries the additional risks of increasing the size and extent of the original perforation and forcing additional air through the perforation into the mediastinum or pleural cavity.

• It is more useful in the thoracic esophagus because it has poor sensitivity in the cervical esophagus.

• Endoscopy may be useful when a perforation is suspected but not proven, especially when trauma (eg, ingested foreign body) is known or suspected to be present.

	TREATMENT	Section 6 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Medical Care:

• Ideal management involves a combination of both conservative and surgical interventions.

• Mainstays of therapy include the following:

• Intravenous volume resuscitation

• Administration of broad-spectrum antibiotics

• Prompt surgical intervention

• The decision to use a conservative (medical intervention only) or an aggressive (medical plus surgical intervention) approach depends on the following factors:
  • Time delay in presentation and diagnosis

  • Extent of perforation

  • Overall medical condition of the patient

• Surgical intervention is the standard of care in most cases, but Cameron et al established a set of criteria in which conservative (nonsurgical) management might be appropriate. These include the following:

• The esophageal disruption should be well contained in the mediastinum.

• The cavity should be well drained back into the esophagus.

• Few symptoms should be present.

• Evidence of clinical sepsis should be minimal.

• Conservative management consists of the following:
  • Intravenous fluids should be instituted.

  • Antibiotics: Imipenem/cilastatin (Primaxin) offers good broad-spectrum coverage.

  • Nasogastric suction should be applied.

  • Keep the patient NPO.

  • Adequate drainage with tube thoracostomy or formal thoracotomy is vital.

  • Early use of nutritional supplementation: Recent evidence suggests that, for hastening recovery, a jejunostomy tube feeding may be favored over hyperalimentation.

Surgical Care:

• Barrett described the first successful surgical repair of the esophagus in 1947. Prior to this, Boerhaave syndrome had virtually 100% mortality.

• Most physicians advocate surgical intervention if the diagnosis is made within the first 24 hours after perforation.

• Direct repair of the rupture and adequate drainage of the mediastinum and pleural cavity provide the best survival rates.

• A left thoracotomy is the preferred approach, although laparotomy may be necessary if the tear extends into the distal esophagus.

• Various techniques, such as the use of an omental flap, may be used to support the primary closure.

• Gastrostomy and jejunostomy tubes often are placed to aid in drainage and nutrition, respectively.

• The vitality of the surrounding tissue is an important factor in selecting the surgical procedure.

• For patients in whom a delay in diagnosis (>24 h) occurred, primary repair may not be possible.

• After 24 hours, the wound edges frequently are edematous, stiff, and friable.

• Various alternatives to primary repair are available.

• The most common includes the creation of an esophageal diversion through the use of a loop or end-cervical esophagostomy. This allows the wound to heal by secondary intention.

• The use of T-tubes also has been described. T-tubes result in the formation of a controlled fistula and a route for drainage of esophageal secretions and refluxed gastric materials.

• One recent study noted that the option of primary repair may be considered for perforations as old as 72 hours.

• Newer techniques involve the use of plastic-covered self-expanding metallic stents.

• They are considered acceptable alternatives only when all other interventional options have been exhausted. Their use in nonmalignant disease is highly controversial because they cannot be removed without considerable risks or not at all.

• Currently, the use of stents in Boerhaave syndrome is recommended for cases that involve extreme delays in diagnosis or a failure of conservative management.

• Expandable metal stents are most commonly used as palliative interventions for unresectable malignant esophageal obstruction.

• These devices bridge the esophageal tear.

• Several types of stents are available, and they vary in flexibility. Recent research holds the promise of biodegradable stents, obviating the necessity for removal.

• Esophageal stents have been associated with a risk of delayed massive hemorrhage in patients with esophageal malignancy.

• The long-term effects of stent placement in Boerhaave syndrome have not been adequately evaluated.

• Late complications of surgical intervention may include the following:
  • Empyema that often requires tube drainage or decortication

  • Esophagotracheal or esophagobronchial fistulas

Consultations:

• Consultation with a thoracic or general surgeon is indicated as soon as the diagnosis is suspected.

• Infectious disease specialist should be consulted for assistance with antimicrobial therapy.

	MEDICATION	Section 7 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

	MISCELLANEOUS	Section 9 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Medical/Legal Pitfalls:

• Failure to diagnose