Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
A 69-year-old male with history of chronic gastro-duodenitis and colonic diverticulosis was admitted to Emergency Department because of postprandial epigastric pain radiating to his left hemiabdomen, associated with vomiting. At physical examination, he was found dyspneic and tachypneic, and severe pain was exacerbated during palpation on the upper abdomen without signs of peritonism. Nasogastric tube positioning yielded enteric, partly coffee ground-like fluid.\nTechnically limited plain radiographs of the thorax and abdomen, obtained with the patient supine, reported predominantly left-sided basal lung opacities consistent with pneumonia and probable associated effusion. Shortly afterwards, because of worsening clinical condition and haemodynamic parameters, urgent contrast-enhanced multidetector CT was requested to rule out acute abnormalities of the thoraco-abdominal aorta.\nInitial CT acquisition [] disclosed an abnormal posterior mediastinal air collection surrounding the collapsed distal esophagus, suggesting the clinically unsuspected presence of a perforation. Bilateral basal lung infiltrates, with extensive involvement of the left inferior lobe, were attributed to aspiration pneumonia. With the patient still on the CT scanner table, further investigation with CT-esophagography was performed with administration of diluted iodinated contrast medium through the nasogastric tube [Figure and ]. Evidence of extraluminal contrast leakage confirmed the presence of a focal wall disruption on the left postero-lateral aspect of the distal esophagus. Both the esophageal perforation and the associated mediastinal contamination were depicted along three planes by means of multiplanar CT reformations. Contrast-enhanced CT acquisition excluded acute aortic diseases.\nAntibiotic treatment with intravenous piperacilline was started. Urgent surgery was performed, including thoracotomic access, posterior mediastinal debridement and irrigation. In agreement with CT findings, after a full-thickness distal esophageal perforation was identified and primarily repaired, without the need for resection. Drainage tube was left in place postoperatively. Supportive therapy and parenteral nutrition therapy were protracted during 32 days of Intensive Care Unit stay. Antibiotics were modified with introduction of cefazoline, according to pus cultures and antibiogram. The patient finally recovered and was discharged from the hospital nearly two months after initial admission.