Research Day
EXPECT THE UNEXPECTED? AN UNUSUAL CASE OF SPONTANEOUS DISTAL ESOPHAGEAL PERFORATION
Document Type
Abstract
Date
2021
Abstract
Introduction: Effort rupture of the esophagus, known as Boerhaave syndrome, is the spontaneous perforation of the esophagus following due to a pressure gradient between the esophagus and thorax. Often associated with severe straining or vomiting, these perforations are transmural and involve all layers of the esophageal wall. Spontaneous perforation is rare, comprising only 15% of cases.
Case: A 45 year-old former basketball player presents with hemoptysis, diaphoresis, and sharp epigastric abdominal pain in the setting of a lodged food bolus. CT scan showed paraesophageal air and pneumomediastinum, and a gastrographin study confirmed diagnosis of a distal esophageal perforation. Cardiothoracic surgery was consulted, and they recommended non-operative management due to the location of this spontaneous perforation. He remained stable and improved with strict medical management and total parenteral nutrition through a PICC line. During the morning of his planned discharge, he experienced new arm pain, which was discovered to be from multiple catheter-associated DVTs. Orchestration with the Cardiothoracic Surgery, Vascular Surgery, and Nutrition teams took place to formulate a plan in the context of his upper GI bleed, iatrogenic hypercoagulability, and large body habitus. He began anticoagulation, stopped antibiotics, and was discharged home with TPN through a tunneled catheter and close outpatient follow-up.
Discussion: Spontaneous Boerhaave syndrome is rare, but the series of events that ensued for our patient seemed even more unlikely. This case shed light on the importance of teamwork in the setting of serial changes and potentially conflicting recommendations, and also that physicians must always remember to expect the unexpected.