Oesophageal rupture
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Transcript of 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…?