Boerhaave Syndrome in an Elderly Woman: A Case Report

Abstract

Boerhaave syndrome is a rare emergency characterized by spontaneous esophageal perforation secondary to severe vomiting. Diagnosis is often difficult due to the nonspecific nature of the symptoms and their similarity to other emergencies. Mortality is high, and it increases if rapid diagnosis and treatment are not provided.

A 76-year-old woman presented to the emergency department after an episode of syncope, hematemesis, and severe retrosternal chest pain. Initial laboratory evaluation showed leukocytosis (12.7 ×10³/µL), elevated C-reactive protein (2.66 mg/dL), and preserved renal function (creatinine 0.68 mg/dL). An initial upper gastrointestinal endoscopy showed detached esophageal mucosa with adherent clots. Contrast-enhanced chest CT scan confirmed esophageal perforation associated with esophageal wall pneumatosis and extensive pneumomediastinum—surgical management with left thoracotomy and esophageal exclusion, mediastinal drainage, and cervical esophagostomy. On postoperative day seven, the patient developed acute kidney injury (creatinine 2.36 mg/dL), metabolic acidosis (HCO₃⁻ 13.4 mmol/L), and hyperlactatemia (4.54 mmol/L), followed by hemodynamic instability and respiratory failure. The patient died 10 days after surgery.

Boerhaave syndrome occurs due to a sudden increase in esophageal intraluminal pressure during vomiting. Its presentation can range from asymptomatic to shock. Diagnosis requires a high index of suspicion, imaging studies, and sometimes upper gastrointestinal endoscopy. Surgery remains the mainstay of treatment, with high mortality if diagnosis and treatment are delayed.

This case highlights the importance of early recognition and multidisciplinary management in patients with severe vomiting, hematemesis, and acute chest pain. Multidisciplinary coordination is key to optimizing the prognosis.