PICTURES IN DIGESTIVE PATHOLOGY

 

An unusual cause of Boerhaave's syndrome in a young patient

 

 

Samuel Raimundo Fernandes¹, Carlos Noronha-Ferreira¹, José Paulo Freire² and José Velosa¹

¹Department of Gastroenterology and Hepatology. Hospital de Santa Maria. Centro Hospitalar Lisboa Norte. Lisbon, Portugal.
²Department of General Surgery. Hospital de Santa Maria. Centro Hospitalar. Lisbon, Portugal

Author contributions: Samuel Raimundo Fernandes (MD), Carlos Noronha Ferreira (MD) and José Freire (MD): elaboration and critical review of the manuscript. José Velosa: critical review of the manuscript.

 

 

Case report

An 18-year-old male patient with a history of atopy and intermittent dysphagia for solids presented to the Emergency Department with sudden onset total dysphagia followed by hematemesis, after ingesting an ibuprofen tablet. Urgent upper gastrointestinal endoscopy revealed a deep laceration (Fig. 1) just above the tablet impacted in the distal esophagus (Fig. 2). Abdominal computed tomography (CT) scan confirmed the suspicion of an esophageal perforation. The impacted tablet was broken up with biopsy forceps, and a covered metallic stent (Hanarostent^® 60/100 x 20/26 mm) was placed across the cardia effectively excluding the fistula (Fig. 3). Recovery was uneventful and the stent was easily removed six weeks later. Follow-up biopsies showed marked mucosal infiltration by eosinophils confirming the diagnosis of eosinophilic esophagitis (EE). The patient was treated with oral budesonide and remains asymptomatic.

 

 

 

 

Discussion

EE is a chronic inflammatory condition of the esophagus typically presenting with dysphagia and food impaction in adulthood (1). Sustained chronic inflammation may weaken the esophagus predisposing to a potential perforation (1). However, perforation unrelated to endoscopic maneuvers has rarely been reported in EE (1-3). In a recent review including 511 patients with EE, perforation occurred in only 2.0%, mostly related with prolonged food bolus impaction (2). While surgery has been classically advocated for this complication, endoscopic management using self-expanding stents may present an alternative (3), as shown in our case. Potential benefits include lower morbidity, earlier resumption of oral feeding and shorter duration of hospitalization.

 

References

1. Lucendo A, Friginal-Ruiz A, Rodríguez B. Boerhaave's syndrome as the primary manifestation of adult eosinophilic esophagitis. Two case reports and a review of the literature. Dis Esophagus 2011;24(2):E11-5. DOI: 10.1111/j.1442-2050.2010.01167.x.         [ Links ]

2. Runge T, Eluri S, Cotton C, et al. Causes and outcomes of esophageal perforation in eosinophilic esophagitis. J Clin Gastroenterol 2016. In press. DOI: 10.1097/MCG.0000000000000718.         [ Links ]

3. Jacobs J, Fatima H, Cote G, et al. Stenting of esophageal perforation in the setting of eosinophilic esophagitis. Dig Dis Sci 2014;60(4):1098-100. DOI: 10.1007/s10620-014-3387-9.         [ Links ]