Boerhaave syndrome

Vipul D Yagnik 
 Ronak Endo-laparoscopy and General Surgical Hospital, Patan, Gujarat, India

Correspondence Address:
Vipul D Yagnik
77, Siddhraj Nagar, Rajmahal Road, Patan 384 265, Gujarat
India

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Dear Sir,

I read an article by Vaidya et al., [1] with great interest. Boerhaave syndrome accounts for 15% of all traumatic perforation of esophagus. Esophageal perforation has the worst prognosis among all gastrointestinal tract perforation. I would like to add some interesting information which you may find useful. In addition to a sharp increase in intraluminal pressure against closed cricopharyngeus, abnormal esophageal mucosa (reflux esophagitis, Barrett's esophagitis, etc.) and lack of muscularis mucosa [2] may also predispose to perforation. In this case, water-soluble contrast showed leak in the pleural cavity. I recommend barium as a contrast agent of choice in the case of suspected lower esophageal perforation above the gastroesophageal junction as barium is inert in the chest and aspiration of gastrograffin (water-soluble contrast) can cause severe life-threatening pneumonitis. I would recommend water-soluble contrast for suspected intraabdominal esophageal perforation as barium will lead to severe barium peritonitis. The use of barium is associated with a higher detection rate for esophageal perforation. The 22% of the patients who had a normal study with water-soluble contrast, a perforation was detected subsequently with the use of barium. [3] Flexible esophagoscopy can be performed with 100% sensitivity and 80% specificity in those who require operative intervention. The authors have mentioned that urgent surgical management is indicated in all patients. [1] I would like to state here that although standard of care is surgical intervention in most cases, Cameron et al. [4] proposed three criteria in which nonoperative management might be appropriate: (1) disruption contained in the mediastinum, (2) cavity well drain back into esophagus, and (3) minimal sign and symptoms of sepsis.

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