Boerhaave Syndrome with Mediastinitis
Shanthi. R
Nursing In charge, Kauvery Hospital, Tirunelveli
Abstract
Boerhaave syndrome is also known as spontaneous rupture of the esophagus, which typically occurs after forceful vomiting. The esophagus is the tube food passes through as it goes from the mouth to the stomach. The contents of the esophagus can pass into the surrounding area in the chest (mediastinum), when there is a hole in the esophagus. This often results in infection of the mediastinum (mediastinitis).
The esophagus may also become perforated as the result of;
- A tumor
- Gastric reflux with ulceration
- Previous surgery on the esophagus
- Swallowing a foreign object or caustic chemicals, such as household cleaners, disk batteries, and battery acid
- Trauma or injury to the chest and esophagus
- Violent vomiting (Boerhaave syndrome)
Background
A 58years old male, came with the complaints of vomiting associated with right flank pain, and abdominal pain with distension. He was initially treated at an outside hospital.
He developed tachycardia and tachypnea with desaturation, hence started NIV. Hence referred here for further evaluation and management.
- Known case of HT/ DM for 3 years
- Known case of Hypothyroidism for 5 years
- Laparoscopic Cholecystectomy (2020)
- Laparoscopic Hernia (2022)
Examination
- Patient awake, obeying commands.
- HR – 136 bpm, BP – 130/90mmHg, Temp – 98.6
- RR – 56, SPO2: 90%
- CVC – S1, S2 present
- RS – Bilateral air entry is present (Decreased air entry in right)
- P/A – Soft
- CNS – NFND
Investigations
| Vital | Results |
|---|---|
| HB | 17.4 |
| PCV | 57.2 |
| Platelet | 229,000 |
| RBC count | 6.59 |
| Total WBC count | 6790 |
| Urea | 34.6mg/dL |
| Creatinine | 1.28mg/dL |
| RBS | 278.5mg/dL |
| Potassium | 4.46mEq/L |
| Sodium | 139.6mEq/L |
| ESR | 25 mm/1hr |
| Bilirubin total | 1.35mg/dL |
| Bilirubin Direct | 0.76mg/ dL |
| Bilirubin indirect | 0.59mg/dL |
| SGOT | 18.0 |
| SGPT | 25.6 |
| ALP | 94.0 |
| Total protein | 6.60g/dL |
| Albumin | 4.00g/dL |
| AG Ratio | 1.53g/dL |
| Blood Group | B POSITIVE |
| Uric acid | 2.93mg/dL |
| HIV | Negative |
| HB sAg: | Negative |
| HCV | Negative |
Course in the hospital
A 58 years’ male came to the hospital. On admission patient was severely tachypneic. He was intubated at ER and resuscitated. CT abdomen revealed Right pneumo hydrothorax with mediastinal shift. Pulmonologist consult obtained.
Right side ICD done, and greenish brown fluid was drained. Patient was suspected as Boerhaave syndrome. He was started on broad-spectrum antibiotics and shifted to ICU.Hemodynamics were unstable. Endoscopy reveled esophageal perforation. Patient’s attender was counselled about the condition.
Patient underwent Esophageal diversion and OG Junction ligation. Feeding Jejunostomy done on 20.03.24. General physician consult obtained. Post- op, patient was better, weaned to pressure support and extubated on 24.03.24. TPN was initiated. Patient was continued on intermittent NIV. Blood culture and tracheal culture taken. Reintubated on 24.03.24. Pulmonologist reviewed.
Patient had episodes of hypoglycemia which was treated accordingly. On 29.03.24 patient underwent Tracheostomy, considering prolonged need for pressure support. FJ feed increased gradually. The patient was awake, cooperative and communicating. Patient was tolerating BIPAP comfortably.
IV antibiotics H2 blocker, Multivitamin, anticoagulant, probiotics, thyroid supplements, bronchodilators and other supportive medicine were continued. Patient was clinically better, comfortable in NIV, hemodynamically stable, systematically improved to mobilizing and ambulation, hence shifted to the ward for further management.
Tracheostomy was plugged at regular intervals and was encouraged to vocalize. Continued the same medicine and added nebulization. ICD was removed, chest physio started. Patient tolerated continuous plugging for more than 48 hr. Hence, patient shifted to ICU for decannulation. Decannulation done on 21.04.24. Patient was comfortable, vocalizing, maintaining airway. Patient stable, Patient general condition improved.
Medications
| Drug | Dose | Frequency |
|---|---|---|
| Inj. Merowin | 1 gm | TDS |
| Inj. Pantocid | 40 mg | OD |
| Inj. Corts | 100 mg | OD |
| Inj. Lesuride | 25 mg | BD |
| Tab. Zolfresh | 10 mg | HS |
| Tab. Thyronorm | 100mg | OD |
| Tab. Abphylline | BD | |
| Tab. Concor | 5 mg | OD |
| Neb. Budecort | 1 – 1 - 1--1 | |
| Syp. Appymax | 10ml | 1-0-0 |
| Syp. Lactihep | 20ml | 0 – 0 – 1 |
Nursing management
Conservative management consists of the following;
- Intravenous fluids should be administered.
- Nasogastric suction should be applied.
- Keep the patient nil per OS (NPO).
- Adequate drainage with tube thoracotomy or formal thoracotomy is vital.
- Early use of nutritional supplementation: Evidence suggests that for hastening recovery, a jejunostomy tube feeding may be favored over hyper alimentation
Frequent monitoring of vital signs is an essential part of management as they offer the first sign of a worsening systemic condition.
Monitoring (both initially at baseline and subsequently at periodic intervals) includes parameters such as pulse rate, blood pressure, respiratory rate, fluid intake and urine output chart, blood glucose, serum electrolytes, serum creatinine and specific cultures.
Completing all necessary documentation including patient notes and discharge.
Outcome of the patient
General condition was good, Vitals stable, hence Discharged with FJ tube with follow- up medical advice.
Shanthi. R
Nursing In charge