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Oesophageal rupture

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Oesophageal rupture

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Oesophageal rupture

  1. 1. THE OESOPHAGEAL RUPTURE PUB QUIZ Thursday Trivia Session Charlie’s Hotel Your host: Dr Deanne Chiu Emergency Education Reg
  2. 2. 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…
  3. 3. 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]
  4. 4. 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]
  5. 5. Q3: EPONYM SCHEPONYM  Spontaneous Oesophageal Rupture, or Boerhaave Syndrome, 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]
  6. 6. 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]
  7. 7. Q5: HIGHLY MORBID Which type of oesophageal rupture has the highest mortality rate? What is the main cause of death? [2 points]
  8. 8. Q6: CLINICAL PRESENTATION  Name the Mackler triad:  1  2  3  Name the Anderson triad (of clinical findings):  1  2  3 [2 points]
  9. 9. Q7: CXR #1 Name the four features of oesophageal rupture that are visible on this film. [4 points]
  10. 10. Q8: CXR #2: Name two features of oesophageal rupture that are visible on these films. [2 points]
  11. 11. Q9: CORNERSTONES OF MX Outline the three management priorities for oesophageal rupture [3 points]
  12. 12. 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]
  13. 13. OESOPHAGEAL RUPTURE - THE ANSWERS Thursday Trivia Session Charlie’s Hotel Your host: Dr Deanne Chiu Emergency Education Reg
  14. 14. 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)
  15. 15. 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
  16. 16. A3: EPONYM SCHNEPONYM  Spontaneous Oesophageal Rupture, or Boerhaave Syndrome, 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]
  17. 17. 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.
  18. 18. 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
  19. 19. 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]
  20. 20. 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? – Polymicrobial Sepsis/Mediastinitis (+/- pleural effusion/s) [2 points]
  21. 21. 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 ]
  22. 22. 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 ]
  23. 23. 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
  24. 24. 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
  25. 25. Q8: CXR #2: Name two features of oesophageal rupture that are visible on these films. [2 points] 1. Pneumo- mediastinum 2. Subcut emphysema
  26. 26. 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)
  27. 27. 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]
  28. 28. 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
  29. 29. ANOTHER PROPOSED MX ALGORITHM http://lifeinthefastlane.com/pulmonary-puzzle-003/
  30. 30. 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]
  31. 31. QUESTIONS?
  32. 32. 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
  33. 33. 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…?

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