Oesophageal rupture

THE OESOPHAGEAL

RUPTURE PUB QUIZ

Thursday Trivia Session

Charlie’s Hotel

Your host: Dr Deanne Chiu

Emergency Education Reg

THE RULES

Two teams

10 questions covering the learning outcome:

Discuss oesophageal rupture

Fighting for the inaugural “Weird and Wonderful Cup”

aka the “Deanne is moving house and has found some

really random stuff to put in a prize hamper”

No biting, name-calling or falling asleep

On your marks… get set…

Q1: THE WEIRD AND WONDERFUL

What’s in the Prize Hamper? Is it:

A) Revlon cosmetics & a copy of The Hunger Games

trilogy

B) Stationery & chocolate biscuits & a cheese board

C) A single serve pack of Tic Tacs & automotive Wash

and Wax

D) A and C

E) All of the above

[1 point]

Q2 : 1ST PART GLORY

Name the anatomical relations of the

oesophagus. Posterior – possible 5 points

Anterior – possible 5 points

Left – possible 4 points

Right – possible 2 points

[16 points]

Q3: EPONYM SCHEPONYM

Spontaneous Oesophageal Rupture, or BoerhaaveSyndrome, was first described in 1724 – True or False?

Boerhaave Syndrome was named after Dr Herman Boerhaave, a German physician – T/F?

Boerhaave Syndrome was described in relation to Baron Jan von Wassenaer, a Dutch Grand Admiral who sustained a large transverse tear of his distal oesophagus due to retching – T/F?

Baron Jan von Wassenaer had roast duck and 3 litres of beer and a self administered emetic 3 days prior to his death – T/F?

Herman Boerhaave had a degree in philosophy and later became a professor of botany and medicine – T/F?

[6 points]

Q4: TYPES AND CAUSES

Please complete the following list of types/causes of Oesophageal

Rupture:

Boerhaave’s Syndrome of “Spontaneous” Oesophageal Rupture n.b.

3 in 4 cases are preceded by vomiting

T-----

B----

P----------

I---------

E--------

P--- O-

Other

Includes caustic, peptic ulcers, foreign body, aortic pathology, diseases of

oesophagus[6 points]

Q5: HIGHLY MORBID

Which type of oesophageal rupture has the

highest mortality rate?

What is the main cause of death?

[2 points]

Q6: CLINICAL PRESENTATION

Name the Mackler triad:

1

2

3

Name the Anderson triad (of clinical findings):

1

2

3

[2 points]

Q7: CXR #1

Name the four

features of

oesophageal

rupture that are

visible on this

film.

[4 points]

Q8: CXR #2: Name two features of oesophageal rupture

that are visible on these films. [2 points]

Q9: CORNERSTONES OF MX

Outline the three management priorities for

oesophageal rupture

[3 points]

Q10: TO CHOP OR NOT TO CHOP?

Name three reasons or situations that might

cause you to consider conservative (non-

operative) management of oesophageal

rupture.

[3 points]

OESOPHAGEAL RUPTURE

- THE ANSWERS

Thursday Trivia Session

Charlie’s Hotel

Your host: Dr Deanne Chiu

Emergency Education Reg

A1: THE WEIRD AND WONDERFUL

What’s in the Prize Hamper? Is it:

A) Revlon cosmetics & a copy of The Hunger Games trilogy

B) Stationery & chocolate biscuits & a cheese board

C) A single serve pack of Tic Tacs & automotive Wash and Wax

D) A and C

E) All of the above (1 point)

A2 : ANATOMICAL RELATIONS OF THE

OESOPHAGUS

Name the anatomical relations of the oesophagus. Posterior –

possible 5 points

Anterior –possible 5 points

Left – possible 4 points

Right – possible 2 points

[16 points]The lack of a serosal layer

makes it vulnerable to rupture or perforation

A3: EPONYM SCHNEPONYM

Spontaneous Oesophageal Rupture, or BoerhaaveSyndrome, was first described in 1724 – TRUE

Boerhaave Syndrome was named after Dr Herman Boerhaave, a German physician – FALSE, he was Dutch

Boerhaave Syndrome was described in relation to Baron Jan von Wassenaer, a Dutch Grand Admiral who sustained a large transverse tear of his distal oesophagus due to retching – TRUE

Baron Jan von Wassenaer had roast duck and 5 cups of beer and a self administered emetic 3 days prior to his death – TRUE

Herman Boerhaave had a degree in philosophy and later became a professor of botany and medicine – TRUE

[6 points]

HERMAN BOERHAAVE

Atrocis, nec descripti prius, morbi historia (1724) is the book in which he describes the case of Baron Jan Gerrit von Wassenaer, the Grand Admiral of the Dutch Fleet and Prefect of Rhineland.

51yo, ate roast duck, took a mild emetic and had four cups of beer.

Unable to vomit but had violent, minimally productive retching

Excruciating chest and abdominal pain “like something had broken or ruptured”. Clear voice and no cough despite severe chest pain.

Autopsy revealed a large transverse tear in the distal oesophagus; significant subcutaneous emphysema and air in the abdominal cavity with the smell of roast duck meat. Bilateral pleural effusions –approx. 3 litres drained.

Legend has it that letters Boerhaave received bore no address and were simply mailed “To the Greatest Physician in the World”. – Tan SY, Hu M.

BOERHAAVE’S SYNDROME

Due to a sudden increase in intraluminal pressures, often due to

violent vomiting or retching, may be related to heavy food and

alcohol intake

Usually longitudinal (cases reported range from 0.6-8.9cm long)

>90% occur in the lower 1/3 of the oesophagus

>90% are in the left posterolateral region

lack of adjacent supporting structures,

thinner musculature in the lower oesophagus and

anterior angulation of the oesophagus at the left diaphragmatic crus

50% of patients have GORD

Ease of pressure transfer from abdominal to thoracic may facilitate rupture

A4: TYPES AND CAUSES

Please complete the following list of types/causes of Oesophageal

Rupture:

Boerhaave’s Syndrome of “Spontaneous” Oesophageal Rupture n.b.

3 in 4 cases are preceded by vomiting

Trauma

Blunt (rare – may be related to intraabdominal crush/pressure increase)

Penetrating (almost all traumas)

Iatrogenic

Endoscopy (most common cause overall)

Post Op

Other

Includes caustic, peptic ulcers, foreign body, aortic pathology, diseases of

oesophagus[6 points]

A5: HIGHLY MORBID

Which type of oesophageal rupture has the highest mortality rate? – Post-emetic – ~ 30% overall

Mortality rates reported ~2% per hour after Sx

If Rx w/in 24 hours – 25% mortality rate

If Rx after 24 hours – 65%

If Rx after 48 hours – 75-89%

No Rx – essentially 100%

What is the main cause of death? – PolymicrobialSepsis/Mediastinitis (+/- pleural effusion/s)

[2 points]

Q6: CLINICAL PRESENTATION - HX

Mackler triad: (Only present in 50% of cases of Boerhaave’s)

Vomiting

Lower chest pain

Cervical subcutaneous emphysema

Typical symptoms can include:

Pain – variable location – lower anterior chest or upper abdomen most common;

may have back or neck pain. May be unable to lie flat due to pain.

Vomiting

Subcutaneous emphysema

Dysphagia or odynophagia; dysphonia

Dyspnoea

GI bleed

[1 point for naming all three ]

Q6: CLINICAL PRESENTATION -

SIGNS Name the Anderson triad (of clinical findings):

Subcutaneous emphysema

Rapid respirations

Abdominal rigidity

Physical signs may include:

Fever

Crepitus/subcutaneous emphysema

Tachycardia, shock

Tachypnoea, cyanosis, altered WOB

Upper abdominal rigidity/signs of perforation/acute abdomen

Local tenderness

Pleural effusions, pneumothorax

[1 point for naming all three ]

CLINICAL PRESENTATION

May not always be the classical middle-aged gouty man with a history of dietary or alcohol overconsumption

1 in 4 cases may not have vomiting

Other reported preceding hx for Boerhaave’s: Straining, Childbirth, Heavy lifting, Seizures, Fits of coughing/laughing/hiccups, Forceful swallowing

Higher risk of perforation with recent instrumentation, older age (>65) or pre-existing upper GI pathology

Mackler’s triad is only present in ~50% of cases

Have a high index of suspicion and move to imaging as necessary

A7: CXR

Name the four

features of

oesophageal

rupture that are

visible on this

film.

[4 points]

1. Subcut

emphysema

2. Pneumo-

mediastinum

4. Prominent renal

outline due to air

3. Air under the

diaphragm

Q8: CXR #2: Name two features of oesophageal rupture

that are visible on these films. [2 points]

1. Pneumo-

mediastinum2. Subcut

emphysema

OTHER IMAGING

Water soluble (gastrograffin) contrast

fluoroscopy/oesophagogram

Sensitivity 60-75%

Barium swallow

Sensitivity 90% for small perforations

BUT barium causes a severe inflammatory response in tissues ie mediastinitis

CT chest +/- upper abdomen

Contrast-enhanced

Useful if oesophagogram negative but high index of suspicion; evaluation of

other diagnoses

Findings may include: pneumomediastinum, extravasation of contrast,

peroesophageal fluid collection, pleural effusion, sighting of passage (air

communication)

A9: MANAGEMENT

Aggressive resuscitation Airway control, oxygenation, IV etc

Early surgical intervention (call Cardiothoracics!) The time between onset of Sx and surgical intervention is the

greatest predictor of patient survival

Various thoracic procedures will depend on extent of injury: Primary repair, stent, resection, drain placement

May need laparotomy for abdominal involvement

Broad spectrum antibiotics To cover gram pos (incl enterococcus), gram neg and

anaerobes.

?Antifungal cover (controversial)

[3 points]

PROPOSED MX ALGORITHM

J. Spapen, J. De Regt, K. Nieboer, G. Verfaillie, P. M. Honoré, and H. Spapen,

“Boerhaave's Syndrome: Still a Diagnostic and Therapeutic Challenge in the 21st

Century,” Case Reports in Critical Care, vol. 2013, Article ID 161286, 4 pages, 2013.

doi:10.1155/2013/161286

ANOTHER PROPOSED MX ALGORITHM

http://lifeinthefastlane.com/pulmonary-puzzle-003/

CONSERVATIVE MANAGEMENT?

Three situations where non-operative Mx may be considered: Presentation >48h

Debilitated pre-morbid condition/significant comorbidity

Contained rupture with minimal symptoms and negligible clinical evidence of sepsis (SIRS negative)

Others include

Tear not involving abdomen/contained to mediastinum/draining to oesophagus/draining to lumen; no neoplasm involved; no associated obstruction; experienced thoracic surgeon available; serial contrast imaging available

[3 points]

QUESTIONS?

REFERENCES http://www.instantanatomy.net/thorax/areas/oesophagus/relations.html

http://www.whonamedit.com/doctor.cfm/2404.html

Tan SY, Hu M. Hermann Boerhaave (1668-1738): 18th century teacher extraordinaire. Singapore Med J. 2004 Jan;45(1):3-5. PMID: 14976574

Esophageal Rupture http://emedicine.medscape.com/article/425410-overview#a03

Esophageal Rupture and Tears in Emergency Medicine Treatment & Management http://emedicine.medscape.com/article/775165-treatment#a1126

Boerhaave Syndrome http://lifeinthefastlane.com/pulmonary-puzzle-003/

J. Spapen, J. De Regt, K. Nieboer, G. Verfaillie, P. M. Honoré, and H. Spapen, “Boerhaave's Syndrome: Still a Diagnostic and Therapeutic Challenge in the 21st Century,” Case Reports in Critical Care, vol. 2013, Article ID 161286, 4 pages, 2013. doi:10.1155/2013/161286

Boerhaave Syndrome http://radiopaedia.org/articles/boerhaave-syndrome

OESOPHAGEAL RUPTURE –

TAKE HOME MESSAGES

Very high mortality rate

Have a very high index of suspicion

Call Cardiothoracics sooner rather than later

AND THE WINNER IS…?