Date Published: September 02, 2019
Publisher: Wolters Kluwer
Author(s): Divya Chalikonda, Joseph Yoo, Drew Johnson, Christina Tofani.
Boerhaave syndrome is a perforation of the esophagus caused by a sudden increase in intraluminal pressure. It is known to be associated with left-sided pleural effusion and mediastinitis, but rarely presents with bilateral effusion. Its association with the presence of a hiatal hernia is unclear. We present a patient with a hiatal hernia who developed bilateral empyemas because of Boerhaave syndrome and was treated with an endoscopically placed esophageal stent.
Boerhaave syndrome is a barogenic tear of the esophagus, typically at the gastroesophageal junction, caused by a sudden increase in intraluminal pressure in the distal esophagus. Classically, patients with Boerhaave syndrome present with chest pain, vomiting, and a unilateral left pleural effusion.1,2 Patients also may have mediastinal free air, subcutaneous emphysema, and mediastinitis.2,3 We describe a case of Boerhaave syndrome causing bilateral empyemas in a patient with a hiatal hernia who presented with nausea and vomiting secondary to diabetic ketoacidosis.
A 74-year-old man with type 2 diabetes mellitus and coronary artery disease was admitted to a nearby hospital with worsening mental status, epigastric abdominal pain, nausea, and emesis. Initial laboratory tests were consistent with diabetic ketoacidosis, and he was admitted for further management. His hospitalization was complicated by progressive hemodynamic instability and hypoxic respiratory failure requiring intubation. Abdominal and pelvic computed tomography (CT) with oral and without intravenous contrast demonstrated bilateral pleural effusions with bibasilar subsegmental consolidation and a large hiatal hernia with a possible small tract extending from the contrast-filled hiatal hernia to the pleura or lung of the medial left lower lobe (Figure 1).
Boerhaave syndrome’s classic presentation, Meckler’s triad (retching, chest pain, and subcutaneous emphysema), is present in less than 10% of cases, which frequently leads to a delayed or missed diagnosis.1 Clinical presentation varies by severity, although, if left untreated, it carries a high mortality rate. Therefore, it should be considered when any 2 of Meckler’s triad are present in a patient’s history.1,2
Author contributions: D. Chalikonda, J. Yoo, and D. Johnson wrote the manuscript. C. Tofani edited the manuscript. D. Chalikonda is the article guarantor.