Abstract
Background and Aims
Boerhaave’s syndrome, involving esophagus rupture, is considered a pathological response to vomiting that may occur just before perforation. However, the mechanism of vomiting and occurrence of this disease have not been clearly demonstrated.
Methods
We identified patients with esophageal perforation between 1995 and 2017 and reviewed endoscopic findings at retching during upper gastrointestinal endoscopy. Finally, we proposed a theory for the underlying pathological mechanism.
Results
We retrospectively investigated 10 patients with esophageal perforation between 1995 and 2017. All patients presented after vomiting associated with large volumes of food and alcohol intake. Nine were treated by primary closure of the perforation and drainage of the thoracic cavity, and one was conservatively treated. In all cases, the perforations were longitudinal tears (1–4 cm) and located in the left of the esophagus, just above the gastric cardia.
Conclusions
We hypothesize that vomiting occurred by retrograde propagation of gastrointestinal motor contraction from the jejunum to the gastric antrum, followed by prolapse of the gastric fornix mucosal into the esophagus. Subsequent esophageal perforation probably resulted from excessive prolapse due to strong contraction and destruction of the muscularis mucosa of the left side of abdominal esophagus, with longitudinal stretching of the whole left esophageal wall due to traction. We also propose that Boerhaave’s syndrome is defined as “post-emetic esophageal perforation” to ensure broader recognition and more expedient diagnosis and treatment. Remaining conditions without any definite causes may be labeled “idiopathic” or “spontaneous” rupture of the esophagus.
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References
Derbes VJ, Mitchell RE. Boerhaave’s Atrocis, nec descripti, morbid historia. The first translation of the classic case report of rupture of the esophagus with annotations. Bull Med Libr Assoc. 1955;43:217–239.
Mackler SA. Spontaneous rupture of the esophagus; an experimental and clinical study. Surg Gynecol Obstet. 1952;94:345–356.
McFarlane GA, Munro A. Oesophageal injury: part 2. The changing face of the management of ruptured esophagus: Boerhaave’s syndrome. Gullet. 1990;1:16–23.
Tesler MA, Eisenberg MM. Collective review spontaneous esophageal rupture. Int Abst Surg. 1963;117:1–10.
Korn O, Oñate JC, López R. Anatomy of the Boerhaave syndrome. Surgery. 2007;141:222–228.
Shepherd HA, Harvey J, Jackson A, et al. Recurrent retching with gastric mucosal prolapse. A proposed prolapse gastropathy syndrome. Dig Dis Sci. 1984;29:121–128. https://doi.org/10.1007/BF01317052.
Kuwano H, Morita M, Mori M, et al. Endoscopic evidence of gastric mucosal prolapse with retching and vomiting. Gastrointest Endosc. 1991;37:585–586.
Ehrlein HJ. Retroperistaltism and duodenogastric reflux in dogs. Scand J Gastroenterol Suppl. 1981;67:29–32.
Weisbrodt NW, Christensen J. Electrical activity of the cat duodenum in fasting and vomiting. Gastroenterology. 1972;63:1004–1010.
Akwari OE. The gastrointestinal tract in chemotherapy induced emesis. A final common pathway. Drugs. 1983;25:18–34.
Lee KY, Park HJ, Chey WY. Studies on mechanism of retching and vomiting in dogs. Effect of peripheral dopamine blocker on myoelectric changes in antrum and upper small intestine. Dig Dis Sci. 1985;30:22–28. https://doi.org/10.1007/BF01318366.
Lang IM, Sarna SK, Condon RE. Gastrointestinal motor correlates of vomiting in the dog: quantification and characterization as an independent phenomenon. Gastroenterology. 1986;90:40–47.
Ando H, Mochiki E, Ohno T, et al. Mechanism of gastrointestinal abnormal motor activity induced by cisplatin in conscious dogs. World J Gastroenterol. 2014;20:15691–15702.
Lang IM, Sarna SK, Dodds WJ. Pharyngeal, esophageal, and proximal gastric responses associated with vomiting. Am J Physiol. 1993;265:G963–G972.
Liebermann-Meffert D, Allgöwer M, Schmid P, et al. Muscular equivalent of the lower esophageal sphincter. Gastroenterology. 1979;76:31–38.
Kuwano H, Matsumata T, Adachi E, et al. Lack of muscularis mucosa and the occurrence of Boerhaave’s syndrome. Am J Surg. 1989;158:420–422.
Acknowledgments
We thank Dr. Soichiro Maekawa MD. PhD, Ms Sayaka Okada, and Kayoko Takahashi for their skillful assistance.
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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Kuwano, H., Yokobori, T., Kumakura, Y. et al. Pathophysiology of Vomiting and Esophageal Perforation in Boerhaave’s Syndrome. Dig Dis Sci 65, 3253–3259 (2020). https://doi.org/10.1007/s10620-019-06028-0
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DOI: https://doi.org/10.1007/s10620-019-06028-0