The Dutch Physician with a Calm Disposition

Today we reviewed a case of Boerhaave Syndrome, named after Dr. Hans Boerhaave who was the first physician to have written about a patient with an esophageal rupture after severe retching.

  • Suspect it in any patient with severe chest discomfort followed by vomiting or retching, [though it can happen without a history of retching]. The presence of subcutaneous emphysema on examination (crepitus) in conjunction with the aforementioned two makes Mackler’s Triad, which is seen in only 14% of patients.
  • The diagnosis is made by contrast esophagram (avoid Barium and chose Gastrografin instead) or by CT scan
  • Treatment is to make the patient strictly NPO, IV antibiotics and surgical consultation
  • Contrast this with a Mallory Weiss tear in which there is a partial thickness, longitudinal laceration of the esophagus or stomach that may present with chest pain, vomiting and hematemesis

We also reviewed the anatomically based framework to abdominal pain, and considered our differential for epigastric pain as well as severe, diffuse abdominal pain.

For epigastric pain, we considered the following:

  • Acute MI
  • Acute pancreatitis
  • Chronic pancreatitis
  • PUD
  • GERD
  • Gastritis
  • Gastroparesis
  • Functional Dyspepsia

For severe diffuse pain

  • obstruction (i.e SBO or hepatobiliary obstruction)
  • perforation (esophageal, gastric, or intestinal)
  • ischemia (ie mesenteric)
  • inflammatory/infectious

 

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