Boerhaave syndrome in emergency abdominal surgery

Aim. To present a case of spontaneous rupture of esophagus taking into account its rarity, diversity of clinical manifestations, complexity of making a diagnosis and treatment of this disease.

Methods. Over the past three years in Kazan City Clinical Hospital №7 three cases of the esophageal damage were registered. The age of the patients ranged from 48 to 67 years, including 2 females and 1 male with spontaneous rupture of esophagus.

Results. A 48-year old patient was admitted to the hospital complaining of vomiting with blood followed by appearance of retrosternal pain which appeared immediately after the holiday and nutritional stress. Emergency fibrogastroduodenoscopy (FEGDS) was performed. Endoscopy revealed signs suggestive of diaphragmatic hernia, and 2 ruptures of esophageal mucous membrane up to 3 cm on the left wall of esophagus above the cardiac sphincter. The diagnosis of Mallory-Weiss syndrome complicated with bleeding was made. Surgery: laparotomy, abdominal revision. The abdominal cavity had dark hemorrhagic discharge, inflamed peritoneum and signs of diffuse peritonitis. Diaphragmatic crurotomy was performed. Revision of abdominal esophagus revealed two longitudinal ruptures of the left esophageal wall 1.5 and 3 cm long 8 cm up from the cardiac sphincter. The ruptures were sutured by discontinuous atraumatic encircling stitch. Lower mediastinum was drained with two double-lumen tubes, the gastric probe was installed through the nose. During the follow up CT scan and ultrasound of thoracic cavity were performed. Liquid nutrition through the probe lasted up to 20 days. The mediastinum was lavaged through double-lumen tube with an aqueous solution of chlorhexidine and chymotrypsin up to 32 days. The patient was discharged on day 34 in a satisfactory condition.

Conclusion. One of the etiologic factors of spontaneous esophageal rupture may be diaphragmatic hernia of the esophagus with increased intraesophageal pressure; early surgical intervention, suturing of esophageal rupture, mediastinal drainage and lavage in the postoperative period are fundamental steps in the treatment of esophageal rupture.