Boerhaave's Syndrome is a condition of spontaneous, longitudinal esophageal tear due to the elevated intraesophageal pressure that that classically follows repeated episodes of vomiting. Since the distal third of the esophagus is inherently weaker than the rest of the esophagus, [1, 2] rupture is seen most often in this segment. Of the different types of spontaneous rupture of the esophageal wall, the tear in Boerhaave's syndrome is full thickness, whereas a Mallory-Weiss tear involves only the mucosa [3, 4].
Furthermore, presentations of esophageal perforation can be distinguished as acute, subacute, and chronic. Acute perforation presents with symptoms within twenty-four hours after rupture. In a subacute rupture, symptoms develop between twenty four hours to two weeks following perforation. With chronic perforation, the onset of symptoms is more insidious, often delaying presentation and diagnosis for weeks to months after rupture [5, 6].
A history of forceful emesis, subxiphoid chest pain, and subcutaneous emphysema (termed the Mackler Triad) is a common triad of symptoms that should suggest acute esophageal rupture [3, 4]. However, atypical presentations in which esophageal rupture mimics pneumonia, myocardial infarction, or aortic aneurysm are sometimes seen as well. Chest films may reveal pneumomediastinum, unilateral effusion, pneumothorax, hydropneumothorax, subcutaneous emphysema, or mediastinal widening. Additionally, x-rays may show radiolucent streaks of air which dissect through fascial planes behind the heart in the shape of the letter "V", the so-called "V-sign" of Naclerio [7, 8]. Other imaging techniques to consider in diagnosing esophageal rupture are barium esophagram and CT chest [9]. In both techniques, there will be evidence of extravasation of food particles or bile from the esophageal lumen into the pleural space or mediastinum [5]. Finally, endoscopy can identify the location of the esophageal defect and confirm the existence of extra-luminal disease or to rule out the diagnosis altogether.
Treatment of spontaneous esophageal rupture can be either non-operative or operative. Nonoperative treatment is best for patients with a contained perforation and the absence of clinical mediastinitis [10, 11]. Such therapy usually includes targeted drainage, intravenous antibiotics, nasogastric decompression, and enteral nutrition. Patients who are either unstable, have clinically significant mediastinitis, or a non-contained rupture, generally require surgery. Guidelines for operative intervention in Boerhaave's syndrome, are based upon perforation size and amount of adjacent contamination [12]. When the rupture is larger than 1 cm with considerable mediastinal contamination, the recommended treatment is T-tube controlled esophagocutaneous fistula, which allows esophageal drainage and promotes healing of the surrounding structures. With amore severe case of rupture, thoracotomy with direct repair may be necessary. Less invasive techniques such as video assisted thorascopic surgery (VATS) [13], endoscopic clipping [14], and placement of endoluminal stents [15] can serve as alternatives to thoracotomy.
