Gastroenterology case presentation

1. Dr. Coetser Prof. Van Zyl, profGrundlingh and dr. Buchel Gastroenterology case presentation

2. A 31 yr old male from Bloemfontein Known HIV positive, started HAART 2 months ago, latest CD4 = 648 Known with chronic diarrhoea since January 2010, isospora belli cultured from stools Now presents with protracted vomiting for 2 weeks, as well as 1 day hx of confusion Complains of odynophagia No haematemesis, no melena stools No chest trauma Our case

3. On examination: • Moderate dehydration • Vitals BP 138/88 Pulse 102 • Abdomen: Loss of skin turgor, not tender, no organomegaly • Surgical emphysema palpable in neck bilaterally • Clear bilateral air-entry in lungs • Special investigations • Na 114 // K 1,5 // urea 36 // creat 666 Our case

4. CXR 2010/04/29 Chest XR

5. CXR 2010/05/10 pneumomediastinum pneumopericardium Chest xr

6. Gastrograffin swallow Our case

7. Etiology, diagnosis and management of Boerhaave’s syndrome

8. Dr. Herman Boerhaave (1668 – 1738) • Leiden, the Netherlands • Described syndrome of oesophageal rupture and mediastinitis after careful autopsy of a great admiral of the Dutch fleet who had spontaneous rupture of his oesophagus following vomiting after overeating History of boerhaave’s syndrome

9. Rare syndrome • Usually due to sudden intraoesophageal rise in pressure, combined with negative intrathoracic pressure, secondary to vomiting or straining • Traumatic • E.g. blunt trauma to the chest • Spontaneous • Caustic ingestion • Pill oesophagitis • Barrett’s ulcer • Infectious ulcers in AIDS • Iatrogenic • Any instrument entering oesophagus, e.g. gastroscopy • Paraoesophageal surgery etiology

10. In >90% cases, full thickness tear occurs in left posterolateral aspect of oesophagus • Usually vertical, 1-4cm in length • Rupture can occur: • Cervical oesophagus • Thoracic oesophagus • Intraabdominal oesophagus • Gastric contents can leak into mediastinum, causing a mediastinitis pathology

11. Classic triad (Mackler’s triad) • vomiting • retrosternal chest pain • surgical emphysema • Not very sensitive, only present in 27% of patients in one series • Can be followed rapidly by odynophagia, dyspnoea, cyanosis, fever and shock • Pleural effusion can be present • Complications • Mediastinitis • Perioesophageal abscess formation Clinical presentation

12. CXR Mediastinal air Intraperitoneal air Cervical oesophageal rupture can present with air in the soft tissues of the neck and prevertebral space Pleural effusion Diagnosis

13. CT scan oesophageal wall oedema extraoesophageal air perioesophageal fluid mediastinal widening air and fluid in pleural spaces diagnosis

14. Gastrografinoesophagogram Barium is superior in revealing small perforations, but can cause an inflammatory response in mediastinum If gastrografin oesophagogram is negative, perform barium swallow diagnosis

15. Gastroscopy has no place in the diagnosis, as both the scope and insufflation of air can cause extention of the perforation and introduce air into the mediastinum diagnosis

16. Spontaneous pneumothorax Intra-alveolar rupture due to barotrauma Myocardial infarction Pancreatitis Lung abscess Pericarditis Differential diagnosis

17. No prospective studies available • Mortality 20-75% regardless of advances in surgical care • 100% mortality if left untreated • Treatment • General measures • Surgical therapy treatment

18. Nil per os Continuous nasogastric suctioning Parenteral feeding Broad-spectrum antibiotic coverage, covering gram positives and anaerobes Treatment: general measures

19. Cervical perforations can be managed without surgery, but thoracic perforations require surgery Surgery to be performed within 24h of presentation, as delays are associated with increased mortality If no underlying oesophageal disease  primary closure If underlying oesophageal disease  oesophageal resection Treatment: surgical therapy

20. Primary repair to be reserved for patients who present within 12h, while those presenting later should have a 2 stage oesophageal resection • Complications of surgical procedures: • Persistent leaks • Mediastinitis • Sepsis • Post-op leaks prevented by reinforcing suture line with fundic wrap, omentum, diaphragmatic wrap or pleura Treatment: surgical therapy

21. Diagnosis by water-soluble swallow study and/or CT scan Uncontained leak Contained leak Presentation <24h Presentation >24h or repair not possible Transthoracic / Closure over T-tube Nil by mouth Transhiatal repair or Decompression NGT Exclusion + diversion IVI antibiotics + or High care /ICU setting Oesophagectomy Nutritional support Decompressing gastrostomy & feeding jejenostomy Delayed reconstruction with colon Deterioration Recovery Treatment algorithm

22. Repeat CXR did not show increased mediastinal air. After consulting cardiothoracic surgery, it was initially decided to manage the condition medically, and the patient was started on tripple antibiotic therapy. The patient had a sudden deterioration in consciousness, thought to be due to hypoxic brain injury following a hypokalaemia-induced dysrhythmia. On day 3 after admission the patient developed signs of systemic sepsis and passed away. Our case

23. Khan, AZ et al. Boerhaave’s syndrome: diagnosis and surgical management. Surgeon, 2007. 1:39-44. Triadafilopoulous, G. Boerhaave’s syndrome: Effort rupture of the esophagus. UpToDate v 17.3 Bibliography