Remarkable computed tomography findings in Boerhaave's syndrome.

Sir,

A 44-year-old chronic alcoholic male was brought to the hospital after he suffered a head injury due to fall under the influence of alcohol. The patient had had repeated and excessive vomiting episodes following a drinking binge just before the fall. He had a 15-year history of alcohol abuse without any other comorbidities. At the time of admission, the patient was drowsy but arousable and disoriented to person and place. The patient was afebrile with a pulse rate of 105 per minute and blood pressure of 110/70 mm Hg. Physical examination was otherwise unremarkable. The stretch reflexes were normal and Babinski sign was not elicited. Pupils were equal, round, and reactive to light. Laboratory parameters were remarkable for the levels of serum glutamate oxaloacetate transaminase (SGOT) 258 U/L, serum glutamate pyruvate transaminase (SGPT) 140 U/L, and serum sodium level 133 mEq/L. Nasogastric tube was inserted to decompress the stomach, and intravenous normal saline along with pantoprazole 40 mg was administered. Computed tomography (CT) scan of brain was normal. The patient's clinical condition had improved significantly on the fifth day when he was discharged. At the time of discharge, the patient had the sole complaint of mild epigastric pain. Oral pantoprazole 40 mg daily and abstinence from alcohol was advised. He presented 15 days later with high-grade fever and severe dysphagia for solids as well as liquids. A CT scan of the neck and thorax revealed presence of gas in the retropharyngeal region extending from C2 to D4 level [Figure 1] and across the midline [Figure 2]. Extension of the gas collection across the midline suggested the involvement of danger space. The pharyngeal airway and trachea were partially compressed and displaced anteriorly [Figure 1]. In addition, collection was seen in the superior mediastinum [Figure 3]. Presence of free air was also seen in the posterior mediastinum. The findings were suggestive of acute mediastinitis secondary to esophageal perforation, likely to be due to Boerhaave's syndrome. Surgical exploration of the mediastinal extension of the prevertebral collection yielded 30 ml of pus. Presence of a small transmural perforation was noted along the posterior wall of upper thoracic esophagus. It was surgically repaired. Patient developed postoperative complications in the form of sepsis, bilateral pleural effusion, and collapse of the left lung, to which he finally succumbed. The pus culture grew a highly resistant strain of Klebsiella.

Figure 1

Presence of gas is seen in the retropharyngeal space from C2 to D4 level on the sagittal computed tomography image

Figure 2

The axial computed tomography image reveals presence of gas in the retropharyngeal region. Extension across the midline suggests involvement of danger space

Figure 3

A rim-enhancing, mixed-density collection is seen in the superior mediastinum on the axial computed tomography image

Boerhaave's syndrome is a transmural perforation of the esophagus, usually associated with forceful emesis. It occurs due to sudden increase in the intramural esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of the cricopharyngeus muscle to relax. The condition is usually seen in alcoholics. The commonest site of esophageal tear in Boerhaave's syndrome is the left posterolateral wall of the lower third of esophagus, just proximal to the gastroesophageal junction. The second most common site of rupture is the subdiaphragmatic or upper thoracic area.[12]

The diagnosis of Boerhaave's syndrome can be difficult due to lack of specific symptoms, and hence, delays in presentation and medical care are not uncommon.[3] Patients may present with symptoms such as chest pain, difficulty in swallowing, and cough. Symptoms due to complications such as mediastinitis, sepsis, and shock usually occur late in the course of the illness.

The retrovisceral space is divided into retropharyngeal and danger spaces by the alar fascia. The retropharyngeal space extends from the level of clivus superiorly to the level of D4 vertebra inferiorly, whereas the danger space extends from the level of clivus superiorly to the diaphragm inferiorly.[4] These spaces act as a potential pathway for extension of neck infections into the mediastinum and vice versa. Gravity, respiration, and negative intrathoracic pressure help the spread of infection along the deep neck spaces.[5] The imaging appearance as seen in this case is striking and very rare for Boerhaave's syndrome.

If not treated early, Boerhaave's syndrome proves fatal. If the condition is not surgically treated within 24 h, the mortality associated with this condition (even after surgical intervention) increases to higher than 50%, and after 48 h, it increases to nearly 90%.[6] In conclusion, Boerhaave's syndrome is an uncommon life-threatening condition which requires a high index of suspicion for early diagnosis, without which it is often fatal. The findings of pneumomediastinum and mediastinal collection on CT scan can be suggestive of the diagnosis in appropriate clinical setting.[7] The remarkable imaging appearance due to the presence of substantial amount of gas in the retropharyngeal space as seen in the case described above is, however, rarely seen.