Boerhaave's syndrome in children: a case report and review of the literature

doi:10.1016/j.jpedsurg.2006.05.003

Journal of Pediatric Surgery

Volume 41, Issue 9, September 2006, Pages 1620-1623

https://doi.org/10.1016/j.jpedsurg.2006.05.003 Get rights and content

Abstract

Boerhaave's syndrome or spontaneous rupture of the esophagus is a rupture of the esophagus after vomiting. It is rare in children, and to date, 26 children have been reported. We present the case of a 5-year-old boy who presented with dyspnea after vomiting and subcutaneous emphysema. The diagnosis was confirmed with esophagoscopy. The patient was successfully treated with a repair of the rupture and a fundoplication. We review the literature on Boerhaave's syndrome in children.

Section snippets

Case report

A 5-year-old boy underwent a partial removal of medulloblastoma. During operation, there were no complications, in particular, no accidental esophageal intubation. Postoperatively, the boy was nauseous and he vomited. A week after the operation, he became dyspneic, and there was a subcutaneous emphysema in his neck and over his chest, which progressed to the upper arms and abdomen. Breath sounds over the right thorax were decreased; the abdomen was tender at palpation. The chest x-ray showed a

Discussion

Boerhaave's syndrome is usually seen in men between 40 and 60 years of age [2]. The classic clinical presentation consists of a history of alcoholism or excessive eating; Meckler's triade of vomiting, pain in the lower thorax, and subcutaneous emphysema; and typical chest x-ray findings, such as pneumomediastinum and hydropneumothorax. Also, other symptoms such as polydipsia, facial and cervical swelling, pericarditis, pneumopericardium, and pneumoperitoneum may be present.

Boerhaave's syndrome

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Cited by (19)

Iatrogenic mediastinitis in bronchiolitis: Importance of avoiding pharyngeal aspiration
2019, Archives de Pediatrie
Citation Excerpt :
Iatrogenic causes are mainly represented, including Bougie dilatation, endoscopic instrumentation, endotracheal intubation, the respiratory suction catheter and nasogastric tube insertion [1]. Spontaneous esophageal rupture, called Boerhaave's syndrome, is rare and caused by a sudden rise of intra-abdominal pressure, in case of vomiting [2]. According to clinical presentation, operative findings, pathogenesis, and acts performed during hospitalization, respiratory suction catheters (used since arrival at the emergency department) or nasogastric tube insertions (used in the inpatient unit, 12 h before the diagnosis of mediastinitis) were suspected.
An 11-month-old infant was hospitalized for his first episode of severe bronchiolitis, with pneumomediastinum on the chest x-ray performed in the emergency room before hospitalization. After a few days, the occurrence of a feverish torticollis motivated a CT scan, revealing mediastinitis. An iatrogenic perforation was objectified in the posterior wall of the esophagus, probably caused by nasopharyngeal aspiration. This exceptional case has never been reported before, except in premature infants. This encouraged us to report this case to change systematic aspiration practices and prefer nasal suctioning in healthy infants with bronchiolitis presenting to the emergency department.
The implications of pneumomediastinum and subcutaneous emphysema for the paediatric otolaryngologist
2017, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
The proposed mechanism of injury in SPM is air leak due to alveolar rupture rather than oesophageal or tracheal perforation. Rupture of the oesophagus is exceedingly rare in children [25]. A recent retrospective study performed by Richer & Sanchez examined a group of patients with varying causes of pneumomediastinum [24].
Three patients presented within a 6-month period with pneumomediastinum. The underlying cause in each was distinct. One case occurred due to blunt laryngeal trauma and required urgent surgical intervention due to a decompensating airway. The second case was related to tracheal perforation secondary to a myofibroblastic tracheal tumour and the final case was related to adenovirus upper respiratory tract infection. Pneumomediastinum may be spontaneous or secondary to an underlying cause. Children should be managed using a multidisciplinary approach. Investigation and management should be influenced by clinical stability and invasive procedures should only be considered in patients who exhibit respiratory distress.
Are esophagrams indicated in pediatric patients with spontaneous pneumomediastinum?
2016, Journal of Pediatric Surgery
Citation Excerpt :
In addition, effort rupture of the esophagus, or Boerhaave's syndrome, is rare in children. Antonis et al. [4] reviewed the 26 cases of pediatric Boerhaave's reported in the literature: of these, 58% of cases occurred in the neonatal period, and 65% were associated with pneumothorax, pleural effusions, or hydropneumothorax, often with a tension component. Engum et al. [5] reported on 25 pediatric patients with proven esophageal perforation: 68% were because of iatrogenic injury, 24% were post traumatic, and in 8% the cause was uncertain.
Spontaneous pneumomediastinum is an infrequent condition in pediatric patients. Presenting symptoms include chest pain, dysphagia, or vomiting, without initiating event. Patients may undergo esophagram because of concern for esophageal perforation as the source for pneumomediastinum, however, abnormalities are rarely demonstrated. The objective of this study is to identify whether esophagrams performed on pediatric patients for spontaneous pneumomediastinum are warranted.
An IRB approved, retrospective study was performed. The radiology information system was queried for the keyword “pneumomediastinum” in reports from 2000 to 2016. 27 patients were identified with spontaneous pneumomediastinum, who underwent 28 esophagrams, and 18 patients with pneumomediastinum secondary to blunt trauma, undergoing 20 esophagrams. Imaging findings recorded included presence of pneumothorax or pleural effusion, amount of imaging performed, radiation dose and fluoroscopy time for esophagrams, and type of contrast used. Clinical data recorded included presenting symptoms, presence of fever, and length of hospital stay.
All esophagrams in patients with both spontaneous and post traumatic pneumomediastinum were negative. Patients were exposed to radiation doses between 61 and 92 μGy m² during esophagrams. Contrast aspiration occurred in one patient.
Esophagrams are not indicated for pediatric patients with spontaneous pneumomediastinum, and may not be warranted in patients with post traumatic pneumomediastinum.
Management of spontaneous pneumomediastinum in children
2015, Journal of Pediatric Surgery
Citation Excerpt :
The final entity that should be considered is esophageal rupture. A literature review by Antonis in 2006 showed that Boerhaave’s syndrome is exceedingly rare in children, reported only 11 times outside of the neonatal age group, many cases in association with serious concurrent illness such as malignancy [17]. Though esophageal disruption was seen neither in our study nor in any of the other pediatric series of pneumomediastinum that we reviewed, if a patient’s history warrants, an esophagram in the ER would be appropriate [5,7,10,18].
We characterize the outcomes of pediatric spontaneous pneumomediastinum in the largest series to date and propose a management pathway.
All patients at our institution with ICD-9 code 518.1 confirmed to have isolated radiographic findings of spontaneous pneumomediastinum between January 2003 and February 2014 were retrospectively reviewed for admission, intensive care unit (ICU) stay, complications, and outcome.
We identified 96 children with 99 episodes, median age 14.1 years (IQR: 8.7–16.4). Primary symptoms were chest pain, cough, and dyspnea. Most were hospitalized (n = 91, 91.9%), with 20 (20.2%) admitted to ICU. Median lengths of stay (LOS) were 1 day (IQR: 1–2) for non-ICU admissions and 3 days (IQR: 2–3) for ICU admissions. The surgical service discharged non-ICU patients 0.94 days earlier than medical services (95% CI 0.38–1.50, p = 0.0014). Asthma affected neither LOS nor ICU admission rates. Follow-up imaging, when obtained (n = 81, 81.8%), did not alter management. Recurrences occurred in three asthmatics, all after one year. Each was rehospitalized and discharged uneventfully. No patient developed pneumomediastinum-related complications (e.g., pneumothorax, pneumopericardium, or mediastinitis).
Spontaneous pneumomediastinum without associated comorbidities can be managed with expectant outpatient observation without further imaging. Children with asthma should be treated independent of spontaneous pneumomediastinum.
Esophageal Rupture and Perforation
2012, Pediatric Surgery, 2-Volume Set: Expert Consult - Online and Print
Esophageal Rupture and Perforation
2012, Pediatric Surgery

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Case reportBoerhaave's syndrome in children: a case report and review of the literature

Abstract

Section snippets

Case report

Discussion

Atrocis, nec descriptis prius, morbi historia. Secundum medicae artis leges conscripta. Lugd Bat Boutes-teniana Leyden, 1724

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