Chapter 39: UGI Bleed- Boerhaave's Syndrome Flashcards
What is it?
Postemetic esophageal rupture
Why is the esophagus susceptible to perforation and more likely to
break down an anastomosis?
No serosa
What is the most common location?
Posterolateral aspect of the esophagus the left), 3 to 5 cm above the GE junction
What is the cause of rupture?
Increased intraluminal pressure, usually caused by violent retching and vomiting
What is the associated risk factor?
Esophageal reflux disease (50%)
What are the symptoms?
Pain postemesis (may radiate to the back, dysphagia)
(Think Boerhaave’s = Boer HEAVES)
What are the signs?
- Left pneumothorax
- Hamman’s sign
- left pleural effusion,
- subcutaneous/mediastinal emphysema
- fever
- tachypnea
- tachycardia
- signs of infection by 24 hours
- neck crepitus
- widened mediastinum on CXR
What is Mackler’s triad?
- Emesis
- Lower chest pain
- Cervical emphysema (subQ air)
What is Hamman’s sign?
“Mediastinal crunch or clicking” produced by the heart beating against air-filled tissues
How is the diagnosis made?
- History
- physical examination
- CXR
- esophagram with water-soluble contrast
What is the treatment?
Surgery within 24 hours to drain the mediastinum and surgically close the perforation and placement of pleural patch; broad-spectrum antibiotics
What is the mortality rate if >24 hours until surgery for perforated
esophagus?
≈33%
Overall, what is the most common cause of esophageal perforation?
Iatrogenic (most commonly cervical esophagus)
45-year-old male with dark blood per rectum, NGT returns clear
fluid and no bile
EGD to rule out UGI source
40-year-old s/p MVC with severe liver injury on hospital day 3
develops significant UGI bleed; EGD reveals no ulcer or gastritis
Hemobilia
