Upper GI Bleeding, C40 P254-270 Flashcards Preview

Section II General Surgery P203Surgical Recall Sixth > Upper GI Bleeding, C40 P254-270 > Flashcards

Flashcards in Upper GI Bleeding, C40 P254-270 Deck (148):
1

What is it?
P254

Bleeding into the lumen of the proximal
GI tract, proximal to the ligament of
Treitz

2

What are the signs/symptoms?
P254

Hematemesis, melena, syncope,
shock, fatigue, coffee-ground emesis,
hematochezia, epigastric discomfort,
epigastric tenderness, signs of
hypovolemia, guaiac-positive stools

3

Why is it possible to have
hematochezia?
P254

Blood is a cathartic and hematochezia
usually indicates a vigorous rate of
bleeding from the UGI source

4

Are stools melenic or melanotic?
P254

Melenic (melanotic is incorrect)

5

How much blood do you
need to have melena?
P254

>50 cc of blood

6

What are the risk factors?
P254

Alcohol, cigarettes, liver disease, burn/
trauma, aspirin/NSAIDs, vomiting,
sepsis, steroids, previous UGI bleeding,
history of peptic ulcer disease (PUD),
esophageal varices, portal hypertension,
splenic vein thrombosis, abdominal aortic
aneurysm repair (aortoenteric fistula),
burn injury, trauma

7

What is the most common
cause of significant UGI
bleeding?
P255

PUD—duodenal and gastric ulcers (50%)

8

What is the common
differential diagnosis of
UGI bleeding?
P255

1. Acute gastritis
2. Duodenal ulcer
3. Esophageal varices
4. Gastric ulcer
5. Esophageal
6. Mallory-Weiss tear

9

What is the uncommon
differential diagnosis of
UGI bleeding?
P255

Gastric cancer, hemobilia, duodenal
diverticula, gastric volvulus, Boerhaave’s
syndrome, aortoenteric fistula,
paraesophageal hiatal hernia, epistaxis,
NGT irritation, Dieulafoy’s ulcer,
angiodysplasia

10

Which diagnostic tests are useful?
P255

History, NGT aspirate, abdominal x-ray,
endoscopy (EGD)

11

What is the diagnostic test of
choice with UGI bleeding?
P255

EGD ( >95% diagnosis rate)

12

What are the treatment
options with the endoscope
during an EGD?
P255

Coagulation, injection of epinephrine
(for vasoconstriction), injection of
sclerosing agents (varices), variceal ligation
(banding)

13

Which lab tests should be performed?
P255

Chem-7, bilirubin, LFTs, CBC,
type & cross, PT/PTT, amylase

14

Why is BUN elevated?
P255

Because of absorption of blood by the GI
tract

15

What is the initial treatment?
P255

1. IVFs (16 G or larger peripheral
IVS x 2), Foley catheter (monitor
fluid status)
2. NGT suction (determine rate and
amount of blood)
3. Water lavage (use warm H(2)O—will
remove clots)
4. EGD: endoscopy (determine etiology/
location of bleeding and possible
treatment—coagulate bleeders)

16

Why irrigate in an upper GI bleed?
P256

To remove the blood clot so you can see
the mucosa

17

What test may help identify
the site of MASSIVE UGI
bleeding when EGD fails to
diagnose cause and blood
continues per NGT?
P256

Selective mesenteric angiography

18

What are the indications for
surgical intervention in UGI
bleeding?
P256

Refractory or recurrent bleeding and site
known, >3 u PRBCS to stabilize or
>6 u PRBCs overall

19

What percentage of patients
require surgery?
P256

≈10%

20

What percentage of patients 
spontaneously stop bleeding?
P256

≈80% to 85%

21

What is the mortality of acute
UGI bleeding?
P256

Overall 10%, 60–80 years of age 15%,
older than 80 years of age 25%

22

What are the risk factors for
death following UGI bleed?
P256

Age older than 60 years
Shock
>5 units of PRBC transfusion
Concomitant health problems

23

PEPTIC ULCER DISEASE (PUD)
What is it?
P256

Gastric and duodenal ulcers

24

PEPTIC ULCER DISEASE (PUD)
What is the incidence in the
United States?
P256

≈10% of the population will suffer from
PUD during their lifetime!

25

PEPTIC ULCER DISEASE (PUD)
What are the possible
consequences of PUD?
P256

Pain, hemorrhage, perforation, obstruction

26

PEPTIC ULCER DISEASE (PUD)
What percentage of patients 
with PUD develops bleeding
from the ulcer?
P256

≈20%

27

PEPTIC ULCER DISEASE (PUD)
Which bacteria are associated with PUD?
P256

Helicobacter pylori

28

PEPTIC ULCER DISEASE (PUD)
What is the treatment?
P257

Treat H. pylori with MOC or ACO
2-week antibiotic regimens:
MOC: Metronidazole, Omeprazole,
Clarithromycin (Think: MOCk)
or
ACO: Ampicillin, Clarithromycin,
Omeprazole

29

PEPTIC ULCER DISEASE (PUD)
What is the name of the sign
with RLQ pain/peritonitis as
a result of succus collecting
from a perforated peptic ulcer?
P257

Valentino’s sign

30

DUODENAL ULCERS
In which age group are
these ulcers most common?
P257

40–65 years of age (younger than
patients with gastric ulcer)

31

DUODENAL ULCERS
What is the ratio of male to
female patients?
P257

Men > women (3:1)

32

DUODENAL ULCERS
What is the most common location?
P257

Most are within 2 cm of the pylorus in
the duodenal bulb

33

DUODENAL ULCERS
What is the classic pain
response to food intake?
P257

Food classically relieves duodenal ulcer pain (Think: Duodenum = Decreased with food)

34

DUODENAL ULCERS
What is the cause?
P257

Increased production of gastric acid

35

DUODENAL ULCERS
What syndrome must you
always think of with a
duodenal ulcer?
P257

Zollinger-Ellison syndrome

36

DUODENAL ULCERS
What are the associated risk factors?
P257

Male gender, smoking, aspirin and other
NSAIDs, uremia, Z-E syndrome,
H. pylori, trauma, burn injury

37

DUODENAL ULCERS
What are the symptoms?
P257

Epigastric pain—burning or aching, usually
several hours after a meal (food, milk,
or antacids initially relieve pain)
Bleeding
Back pain
Nausea, vomiting, and anorexia
↓ appetite

38

DUODENAL ULCERS
What are the signs?
P258

Tenderness in epigastric area (possibly),
guaiac-positive stool, melena,
hematochezia, hematemesis

39

DUODENAL ULCERS
What is the differential diagnosis?
P258

Acute abdomen, pancreatitis, cholecystitis,
all causes of UGI bleeding, Z-E
syndrome, gastritis, MI, gastric ulcer,
reflux

40

DUODENAL ULCERS
How is the diagnosis made?
P258

History, PE, EGD, UGI series
(if patient is not actively bleeding)

41

DUODENAL ULCERS
When is surgery indicated
with a bleeding duodenal ulcer?
P258

Most surgeons use: >6 u PRBC
transfusions, >3 u PRBCs needed to
stabilize, or significant rebleed

42

DUODENAL ULCERS
What EGD finding is
associated with rebleeding?
P258

Visible vessel in the ulcer crater, recent
clot, active oozing

43

DUODENAL ULCERS
What is the medical treatment?
P258

PPIs (proton pump inhibitors) or H(2)
receptor antagonists—heal ulcers in
4 to 6 weeks in most cases
Treatment for H. pylori

44

DUODENAL ULCERS
When is surgery indicated?
P258

The acronym “I HOP”:
Intractability
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation

45

DUODENAL ULCERS
How is a bleeding duodenal
ulcer surgically corrected?
P258

Opening of the duodenum through the
pylorus
Oversewing of the bleeding vessel

46

DUODENAL ULCERS
What artery is involved with
bleeding duodenal ulcers?
P258

Gastroduodenal artery

47

DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Truncal vagotomy?
P258

Pyloroplasty

48

DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal perforation?
P259

Graham patch (poor candidates, shock,
prolonged perforation)
Truncal vagotomy and pyloroplasty
incorporating ulcer
Graham patch and highly selective
vagotomy
Truncal vagotomy and antrectomy
(higher mortality rate, but lowest
recurrence rate)

49

DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal obstruction resulting from duodenal
ulcer scarring (gastric outlet obstruction)?
P259

Truncal vagotomy, antrectomy, and
gastroduodenostomy (BI or BII)
Truncal vagotomy and drainage procedure
(gastrojejunostomy)

50

DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal ulcer intractability?
P259

PGV (highly selective vagotomy)
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII
(especially if there is a coexistent
pyloric/prepyloric ulcer) but
associated with a higher mortality

51

DUODENAL ULCERS
Which ulcer operation has
the highest ulcer recurrence
rate and the lowest dumping
syndrome rate?
P259

PGV (proximal gastric vagotomy)

52

DUODENAL ULCERS
Which ulcer operation has
the lowest ulcer recurrence
rate and the highest
dumping syndrome rate?
P259

Vagotomy and antrectomy

53

DUODENAL ULCERS
Why must you perform a
drainage procedure
(pyloroplasty, antrectomy)
after a truncal vagotomy?
P259

Pylorus will not open after a truncal
vagotomy

54

DUODENAL ULCERS
Which duodenal ulcer
operation has the lowest
mortality rate?
P259

PGV (1/200 mortality), truncal vagotomy
and pyloroplasty (1–2/200), vagotomy
and antrectomy (1%–2% mortality)
Thus, PGV is the operation of choice
for intractable duodenal ulcers with
the cost of increased risk of ulcer
recurrence

55

DUODENAL ULCERS
What is a “kissing” ulcer?
P260

Two ulcers, each on opposite sides of the
lumen so that they can “kiss”

56

DUODENAL ULCERS
Why may a duodenal rupture
be initially painless?
P260

Fluid can be sterile, with a nonirritating
pH of 7.0 initially

57

DUODENAL ULCERS
Why may a perforated duodenal ulcer present as lower quadrant abdominal pain?
P260

Fluid from stomach/bile drains down
paracolic gutters to lower quadrants and
causes localized irritation

58

GASTRIC ULCERS
In which age group are these
ulcers most common?
P260

40–70 years old (older than the duodenal
ulcer population)
Rare in patients younger than 40 years

59

GASTRIC ULCERS
How does the incidence in
men compare with that of women?
P260

Men > women

60

GASTRIC ULCERS
Which is more common
overall: gastric or duodenal ulcers?
P260

Duodenal ulcers are more than twice as
common as gastric ulcers
(Think: Duodenal = Double rate)

61

GASTRIC ULCERS
What is the classic pain
response to food?
P260

Food classically increases gastric ulcer
pain

62

GASTRIC ULCERS
What is the cause?
P260

Decreased cytoprotection or gastric
protection (i.e., decreased bicarbonate/
mucous production)

63

GASTRIC ULCERS
Is gastric acid production
high or low?
P260

Gastric acid production is normal or low!

64

GASTRIC ULCERS
Which gastric ulcers are
associated with increased
gastric acid?
P260

Prepyloric
Pyloric
Coexist with duodenal ulcers

65

GASTRIC ULCERS
What are the associated risk factors?
P260

Smoking, alcohol, burns, trauma, CNS
tumor/trauma, NSAIDs, steroids, shock,
severe illness, male gender, advanced age

66

GASTRIC ULCERS
What are the symptoms?
P260

Epigastric pain
+/- Vomiting, anorexia, and nausea

67

GASTRIC ULCERS
How is the diagnosis made?
P261

History, PE, EGD with multiple biopsy
(looking for gastric cancer)

68

GASTRIC ULCERS
What is the most common location?
P261

≈70% are on the lesser curvature; 5% are
on the greater curvature

69

GASTRIC ULCERS
When and why should biopsy
be performed?
P261

With all gastric ulcers, to rule out gastric
cancer
If the ulcer does not heal in 6 weeks after
medical treatment, rebiopsy (always
biopsy in O.R. also) must be performed

70

GASTRIC ULCERS
What is the medical treatment?
P261

Similar to that of duodenal ulcer—PPIs or
H(2) blockers, Helicobacter pylori treatment

71

GASTRIC ULCERS
When do patients with
gastric ulcers need to have
an EGD?
P261

1. For diagnosis with biopsies
2. 6 weeks postdiagnosis to confirm
healing and rule out gastric cancer!

72

GASTRIC ULCERS
What are the indications for surgery?
P261

The acronym “I CHOP”:
Intractability

Cancer (rule out)
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation
(Note: Surgery is indicated if gastric
cancer cannot be ruled out)

73

GASTRIC ULCERS
What is the common
operation for hemorrhage,
obstruction, and perforation?
P261

Distal gastrectomy with excision of the
ulcer without vagotomy unless there is
duodenal disease (i.e., BI or BII)

74

GASTRIC ULCERS
What are the options for
concomitant duodenal and
gastric ulcers?
P261

Resect (BI, BII) and truncal vagotomy

75

GASTRIC ULCERS
What is a common option
for surgical treatment of a
pyloric gastric ulcer?
P261

Truncal vagotomy and antrectomy
(i.e., BI or BII)

76

c
What is a common option for
a poor operative candidate
with a perforated gastric ulcer?
P261

Graham patch

77

GASTRIC ULCERS
What must be performed in
every operation for gastric ulcers?
P262

Biopsy looking for gastric cancer

78

GASTRIC ULCERS
Define the following terms:
Cushing’s ulcer
P262

PUD/gastritis associated with neurologic
trauma or tumor
(Think: Dr. Cushing = NeuroSurgeon = CNS)

79

GASTRIC ULCERS
Define the following terms:
Curling’s ulcer
P262

PUD/gastritis associated with major burn
injury (Think: curling iron burn)

80

GASTRIC ULCERS
Define the following terms:
Marginal ulcer
P262

Ulcer at the margin of a GI anastomosis

81

GASTRIC ULCERS
Define the following terms:

P262

Dieulafoy’s ulcer

82

PERFORATED PEPTIC ULCER
What are the symptoms?
P262

Acute onset of upper abdominal pain

83

PERFORATED PEPTIC ULCER
What causes pain in the
lower quadrants?
P262

Passage of perforated fluid along colic
gutters

84

PERFORATED PEPTIC ULCER
What are the signs?
P262

Decreased bowel sounds, tympanic
sound over the liver (air), peritoneal
signs, tender abdomen

85

PERFORATED PEPTIC ULCER
What are the signs of posterior duodenal erosion/perforation?
P262

Bleeding from gastroduodenal artery
(and possibly acute pancreatitis)

86

PERFORATED PEPTIC ULCER
What sign indicates anterior
duodenal perforation?
P262

Free air (anterior perforation is more
common than posterior)

87

PERFORATED PEPTIC ULCER
What is the differential diagnosis?
P262

Acute pancreatitis, acute cholecystitis,
perforated acute appendicitis, colonic
diverticulitis, MI, any perforated viscus

88

PERFORATED PEPTIC ULCER
Which diagnostic tests are indicated?
P262

X-ray: free air under diaphragm or in
lesser sac in an upright CXR (if upright
CXR is not possible, then left lateral
decubitus can be performed because air
can be seen over the liver and not
confused with the gastric bubble)

89

PERFORATED PEPTIC ULCER
What are the associated lab findings?
P263

Leukocytosis, high amylase serum
(secondary to absorption into the blood
stream from the peritoneum)

90

PERFORATED PEPTIC ULCER
What is the initial treatment?
P263

NPO: NGT (↓ contamination of the
peritoneal cavity)
IVF/Foley catheter
Antibiotics/PPIs
Surgery

91

PERFORATED PEPTIC ULCER
What is a Graham patch?
P263

Piece of omentum incorporated into the
suture closure of perforation

92

PERFORATED PEPTIC ULCER
What are the surgical
options for treatment of a
duodenal perforation?
P263

Graham patch (open or laparoscopic)
Truncal vagotomy and pyloroplasty
incorporating ulcer
Graham patch and highly selective
vagotomy

93

PERFORATED PEPTIC ULCER
What are the surgical options
for perforated gastric ulcer?
P263

Antrectomy incorporating perforated
ulcer, Graham patch or wedge resection
in unstable/poor operative candidates

94

PERFORATED PEPTIC ULCER
What is the significance of
hemorrhage and perforation
with duodenal ulcer?
P263

May indicate two ulcers (kissing);
posterior is bleeding and anterior is
perforated with free air

95

PERFORATED PEPTIC ULCER
What type of perforated
ulcer may present just like
acute pancreatitis?
P263

Posterior perforated duodenal ulcer
into the pancreas (i.e., epigastric pain
radiating to the back; high serum
amylase)

96

PERFORATED PEPTIC ULCER
What is the classic difference
between duodenal and
gastric ulcer symptoms as
related to food ingestion?
P263

Duodenal = decreased pain
Gastric = increased pain
(Think: Duodenal = Decreased pain)

97

TYPES OF SURGERIES
Define the following terms:
Graham patch
P264

For treatment of duodenal perforation in
poor operative candidates/unstable
patients
Place viable omentum over perforation
and tack into place with sutures

98

TYPES OF SURGERIES
Define the following terms:
Truncal vagotomy
P264

Resection of a 1- to 2-cm segment of
each vagal trunk as it enters the
abdomen on the distal esophagus,
decreasing gastric acid secretion

99

TYPES OF SURGERIES
What other procedure must
be performed along with a
truncal vagotomy?
P264

“Drainage procedure” (pyloroplasty,
antrectomy, or gastrojejunostomy),
because vagal fibers provide relaxation of
the pylorus, and, if you cut them, the
pylorus will not open

100

TYPES OF SURGERIES
Define the following terms:
Vagotomy and pyloroplasty
P264 (picture)

Pyloroplasty performed with vagotomy to
compensate for decreased gastric emptying

101

TYPES OF SURGERIES
Define the following terms:
Vagotomy and antrectomy
P265

Remove antrum and pylorus in addition
to vagotomy; reconstruct as a Billroth
I or II

102

TYPES OF SURGERIES
What is the goal of duodenal
ulcer surgery?
P265

Decrease gastric acid secretion (and fix
IHOP)

103

TYPES OF SURGERIES
What is the advantage of
proximal gastric vagotomy
(highly selective vagotomy)?
P265 (picture)

No drainage procedure is needed; vagal
fibers to the pylorus are preserved; rate
of dumping syndrome is low

104

TYPES OF SURGERIES
What is a Billroth I (BI)?
P265 (picture)

Truncal vagotomy, antrectomy, and
gastroduodenostomy (Think: BI = ONE
limb off of the stomach remnant)

105

TYPES OF SURGERIES
What are the contraindica-tions for a Billroth I?
P265

Gastric cancer or suspicion of gastric
cancer

106

TYPES OF SURGERIES
What is a Billroth II (BII)?
P266 (picture)

Truncal vagotomy, antrectomy, and
gastrojejunostomy (Think: BII = TWO
limbs off of the stomach remnant)

107

TYPES OF SURGERIES
What is the Kocher maneuver?
P266

Dissect the left lateral peritoneal
attachments to the duodenum to allow
visualization of posterior duodenum

108

STRESS GASTRITIS
What is it?
P266

Superficial mucosal erosions in the
stressed patient

109

STRESS GASTRITIS
What are the risk factors?
P266

Sepsis, intubation, trauma, shock, burn,
brain injury

110

STRESS GASTRITIS
What is the prophylactic treatment?
P266

H(2) blockers, PPIs, antacids, sucralfate

111

STRESS GASTRITIS
What are the signs/symptoms?
P266

NGT blood (usually), painless (usually)

112

STRESS GASTRITIS
How is it diagnosed?
P266

EGD, if bleeding is significant

113

STRESS GASTRITIS
What is the treatment for gastritis?
P266

LAVAGE out blood clots, give a maximum
dose of PPI in a 24-hour IV drip

114

MALLORY-WEISS SYNDROME
What is it?
P266

Post-retching, postemesis longitudinal
tear (submucosa and mucosa) of the
stomach near the GE junction; approximately
three fourths are in the stomach

115

MALLORY-WEISS SYNDROME
For what percentage of all
upper GI bleeds does this
syndrome account?
P267

≈10%

116

MALLORY-WEISS SYNDROME
What are the causes of a tear?
P267

Increased gastric pressure, often
aggravated by hiatal hernia

117

MALLORY-WEISS SYNDROME
What are the risk factors?
P267

Retching, alcoholism (50%), >50% of
patients have hiatal hernia

118

MALLORY-WEISS SYNDROME
What are the symptoms?
P267

Epigastric pain, thoracic substernal pain,
emesis, hematemesis

119

MALLORY-WEISS SYNDROME
What percentage of patients
will have hematemesis?
P267

85%

120

MALLORY-WEISS SYNDROME
How is the diagnosis made?
P267

EGD

121

MALLORY-WEISS SYNDROME
What is the “classic” history?
P267

Alcoholic patient after binge drinking—
first, vomit food and gastric contents,
followed by forceful retching and bloody
vomitus

122

MALLORY-WEISS SYNDROME
What is the treatment?
P267

Room temperature water lavage (90% of
patients stop bleeding), electrocautery,
arterial embolization, or surgery for
refractory bleeding

123

MALLORY-WEISS SYNDROME
When is surgery indicated?
P267

When medical/endoscopic treatment fails
( >6 u PRBCs infused)

124

MALLORY-WEISS SYNDROME
Can the Sengstaken-
Blakemore tamponade
balloon be used for
treatment of Mallory-Weiss
tear bleeding?
P267

No, it makes bleeding worse
Use the balloon only for bleeding
from esophageal varices

125

ESOPHAGEAL VARICEAL BLEEDING
What is it?
P267

Bleeding from formation of esophageal
varices from back up of portal pressure
via the coronary vein to the submucosal
esophageal venous plexuses secondary to
portal hypertension from liver cirrhosis

126

ESOPHAGEAL VARICEAL BLEEDING
What is the “rule of two
thirds” of esophageal
variceal hemorrhage?
P268

Two thirds of patients with portal
hypertension develop esophageal
varices
Two thirds of patients with esophageal
varices bleed

127

ESOPHAGEAL VARICEAL BLEEDING
What are the signs/symptoms?
P268

Liver disease, portal hypertension,
hematemesis, caput medusa, ascites

128

ESOPHAGEAL VARICEAL BLEEDING
How is the diagnosis made?
P268

EGD (very important because only 50%
of UGI bleeding in patients with known
esophageal varices are bleeding from the
varices; the other 50% have bleeding
from ulcers, etc.)

129

ESOPHAGEAL VARICEAL BLEEDING
What is the acute medical treatment?
P268

Lower portal pressure with somatostatin
and vasopressin

130

ESOPHAGEAL VARICEAL BLEEDING
In the patient with CAD,
what must you give in
addition to the vasopressin?
P268

Nitroglycerin—to prevent coronary
artery vasoconstriction that may result
in an MI

131

ESOPHAGEAL VARICEAL BLEEDING
What are the treatment options?
P268

Sclerotherapy or band ligation via
endoscope, TIPS, liver transplant

132

ESOPHAGEAL VARICEAL BLEEDING
What is the Sengstaken-
Blakemore balloon?
P268

Tamponades with an esophageal balloon
and a gastric balloon

133

ESOPHAGEAL VARICEAL BLEEDING
What is the problem with shunts?
P269

Decreased portal pressure, but increased
encephalopathy

134

BOERHAAVE’S SYNDROME
What is it?
P269

Postemetic esophageal rupture

135

BOERHAAVE’S SYNDROME
Who was Dr. Boerhaave?
P269

Dutch physician who first described the
syndrome in the Dutch Grand Admiral
Van Wassenaer in 1724

136

BOERHAAVE’S SYNDROME
Why is the esophagus
susceptible to perforation
and more likely to break
down an anastomosis?
P269

No serosa

137

BOERHAAVE’S SYNDROME
What is the most common location?
P269

Posterolateral aspect of the esophagus (on
the left), 3 to 5 cm above the GE junction

138

BOERHAAVE’S SYNDROME
What is the cause of rupture?
P269

Increased intraluminal pressure, usually
caused by violent retching and vomiting

139

BOERHAAVE’S SYNDROME
What is the associated risk factor?
P269

Esophageal reflux disease (50%)

140

BOERHAAVE’S SYNDROME
What are the symptoms?
P269

Pain postemesis (may radiate to the back,
dysphagia)

141

BOERHAAVE’S SYNDROME
What are the signs?
P269

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

142

BOERHAAVE’S SYNDROME
What is Mackler’s triad?
P269

1. Emesis
2. Lower chest pain
3. Cervical emphysema (subQ air)

143

BOERHAAVE’S SYNDROME
What is Hamman’s sign?
P269

“Mediastinal crunch or clicking”
produced by the heart beating against
air-filled tissues

144

BOERHAAVE’S SYNDROME
How is the diagnosis made?
P269

History, physical examination, CXR,
esophagram with water-soluble contrast

145

BOERHAAVE’S SYNDROME
What is the treatment?
P270

Surgery within 24 hours to drain the
mediastinum and surgically close the
perforation and placement of pleural
patch; broad-spectrum antibiotics

146

BOERHAAVE’S SYNDROME
What is the mortality rate 
if less than 24 hours until
surgery for perforated
esophagus?
P270

≈15%

147

BOERHAAVE’S SYNDROME
What is the mortality rate 
if more than 24 hours until
surgery for perforated
esophagus?
P270

≈33%

148

BOERHAAVE’S SYNDROME
Overall, what is the
most common cause of
esophageal perforation?
P270

Iatrogenic (most commonly cervical
esophagus)