P0664 - “Eating on the Run”: A Case Report of Boerhaave’s Syndrome Presenting as a Complication of Eosinophilic Esophagitis

Emmanuel Attah, MD¹, Donevan Westerveld, MD², David Wan, MD^1
1New York-Presbyterian/Weill Cornell Medical Center, New York, NY; ²New York-Presbyterian-Weill Cornell Medical Center, New York, NY

Introduction: Boerhaave's Syndrome (BS), also known as effort rupture of the esophagus, is a rare disease that carries significant morbidity and mortality if the diagnosis is delayed. It commonly occurs in the setting of an acute rise in intraesophageal pressure in patient with no underlying esophageal pathology but conditions such as eosinophilic esophagitis (EoE) & esophageal ulcers are associated with increased risk.

Case Description/Methods: We report the case of a 34-year-old man who presented to the emergency room with chest pain and hematemesis after "eating on the run." On presentation, his vital signs were stable however, he appeared to be in acute distress. Labs were notable for a white count of 18,960/ml. Computed tomography (CT) revealed pneumomediastinum with small bilateral pleural effusions. He was made NPO & started on emperic antibiotics and antifungals. Emergent EGD showed a ringed esophagus, an esophageal stricture at 35 cm consistent with EoE, and a 10 cm linear esophageal tear terminating in the gastroesophageal junction. A 155 mm x 23 mm fully covered metal stent (FCMS) was placed across the tear. An esophagram 1 week post EGD showed no leak. He was started on a clear liquid diet after which he developed fevers. Repeat CT revealed an enlarging loculated pleural fluid collection adjacent to the stent. He was made NPO & taken for a video-assisted thoracoscopic surgery with washout for empyema. A repeat EGD was done for PEJ tube placement and stent removal. Intraprocedural fluoroscopy showed a persistent leak. The defect was closed with a single endoscopically placed suture. His fevers resolved & he was discharged. He restarted an oral diet ~ 6 weeks after discharge which he tolerated well.

Discussion: Management of BS with a large tear typically requires surgery. Endoscopic management remains controversial given concerns of worsening perforation due to insufflation and passing of the endoscope. Endoscopic therapy conventionally consist of FCMS placement. Our patient with previously undiagnosed EoE who presented with BS failed FCMS placement due to a persistent leak but suturing of the defect resolved the leak. Literature search reveals a case of BS successfully treated with combination of suturing & stent placement [1]. Perhaps, endoscopic suturing with FCMS placement may be a reasonable therapy for a large tear.
References
1. Chen, Alan MD; Kim, Raymond MD Boerhaave Syndrome Treated with Endoscopic Suturing, American Journal of Gastroenterology: October 2018 - Volume 113 - Issue - p S963


Figure: Multipart Image (figure 1 - CT Chest, figure 2 - EGD findings, figure 3 - CXR after stent placement, figure 4 - Esophagram)


Disclosures:
Emmanuel Attah indicated no relevant financial relationships.
Donevan Westerveld indicated no relevant financial relationships.
David Wan indicated no relevant financial relationships.


Emmanuel Attah, MD¹, Donevan Westerveld, MD², David Wan, MD¹. P0664 - “Eating on the Run”: A Case Report of Boerhaave’s Syndrome Presenting as a Complication of Eosinophilic Esophagitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.