A case of Boerhaave syndrome with esophago- pleural fistula

1. A case of Boerhaave syndrome with esophago- pleural
fistula
M Sagar, A Handique, D. Lynser, C.Daniala, B Wankhar, P Phukan, G
kumar, S Paul, V Joseph, S Borah, L Gupta , A Chakraborty
Department of Radiology & Imaging
North Eastern Indira Gandhi Regional Institute of Health & Medical Science, Shillong

2. Boerhaave syndrome refers to oesophageal rupture secondary to forceful vomiting and retching.
•More prevalent in males, with alcoholism as risk factor.
•Estimated incidence is ~ 1:6000.
•Esophageal perforations are rare, with an incidence of 3.1 per 1,000,000 per year,
•One of the most lethal disease of GIT and survival is usually in days.
Case report - 52 year old male, a farmer by occupation presenting with sudden severe vomiting
while having dinner with severe left sided chest pain, Breathing difficulty with poor general
condition, high risk for surgery

3. Figure 1: Chest
Radiograph AP view- left
hydropneumothorax( )with
left paravertebral bubbly air
shadows ( )
Figure 2A, 2B, 2C: Coronal and axial NECT images of thorax reveals
oesophageal rent ( ) above the diaphragm communicating with left
pleural cavity (. ). Bilateral pleural effusion with hydropneumothorax on
left side is also noted. [ Chest Drain showed undigested Food materials]
1 2A
2B 2C
Diagnostic imaging:

4. Treatment- Intervention radiology
Patient was first treated with percutaneous chest drain insertion for hydropneumothorax followed
by deployment of fully covered oesophageal stent across the oesophageal perforation.
Figure 3A, 3B: Fluoroscopic image and Chest X ray
AP view - done immediately after fully covered
oesophageal stent ( ) deployment- radio dense
oesophageal stent in situ noted.
3A
3B
1. Chest tube drainage followed by oesophageal stent deployment-

5. Figure 4A, 4B: Gastrostomy tube ( )
in-situ in left hypochondriac region and confirmed
by fluoroscopic image of abdomen– Gastrostomy
was performed after 1 week of oesophageal
stenting, gradual improvement in general status
was evident.
Figure 5A, 5B, 5C: 12 mm vascular plug ( ) deployed (Cera)
through gastrostomy access and one can appreciate the catheter &
guidewire negotiated across the fistula adjacent to covered
oesophageal stent ( )
5C: post procedure follow up (after 1 month) CT thorax-
multiplanar reconstructed image shows hyperdense fully covered
oesophageal stent ( ) and also the vascular plug sealing the
oesophageal rent ( )
4A
4B
5A 5B 5C
3. Vascular plug deployment for oesophageal
perforation
2. Gastrostomy- after one week post
oesophageal stent deployment

6. Conclusion
 This case report highlights the importance of prompt
diagnosis and role of minimally invasive intervention
radiological procedures in emergencies.
 Reduces the mortality rate significantly from 35% to
6.2% in patients with Boerhaave syndrome, if treated in
the first 24 hours.
 Most unfit for definitive primary surgical repair of
oesophagus at the time of presentation due to poor
general condition and associated mediastinitis and
/sepsis.
Discussion
 Boerhaave syndrome is thought to occur due to a
forceful ejection of gastric contents in an
unrelaxed oesophagus against a closed upper
oesophageal sphincter/cricopharyngeus.
 Approximately 90% occur along the left
posterolateral wall of the distal oesophagus, 3-6
cm above the oesophageal hiatus of the
diaphragm.
 Diagnosis is often overlooked in emergency
clinical settings.
References
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