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Only for medical professionals to read and learn together.
Cardiovascular disease is a common cause of chest pain after long-distance running.
However, for the ultra-long-distance runner reported by Pasternak A et al.
in the BMJ Case Rep magazine, the cause of sudden chest pain may surprise you.
Case introduction This is a 37-year-old male athlete who participated in a 100-mile ultramarathon for the first time.
After a long journey, after leaving the permanent rescue station for a few hundred meters, the athlete was about to swallow an over-the-counter non-steroidal anti-inflammatory drug for temporary pain relief.
The patient suddenly developed nausea, vomiting, and eventually The medicine spit out.
However, when vomiting, the patient had sudden severe left chest pain and right upper abdominal pain, accompanied by difficulty breathing.
The patient feels pain similar to that of a rib fracture, and lying on his back can significantly worsen his chest pain.
The patient’s vital signs measured by the medical staff at the rescue station were normal, and the blood oxygen saturation was 95%.
Medical staff activated emergency medical services and rushed the patient to the nearest emergency room.
The emergency doctor rechecked the vital signs as: breathing 22 times/min, pulse rate 77 times/min, blood oxygen saturation 93%.
There was no abnormality in the electrocardiogram.
Blood test: white blood cell count rose to 17.
8 × 109/L, with neutrophil nucleus shifting to the left.
Urea nitrogen and creatinine increased to 50 mg/dl, 203.
3 μmol/l, CK 5349U/L, and BNP slightly increased to 614 pg/dL.
Troponin I slightly increased to 0.
09 ng/mL, and d-dimer increased to 598 ng/mL (returned to normal at the hospital review). Imaging examination: chest radiograph showed large infiltrates of the left lung floor, accompanied by mediastinal emphysema and scattered air in the soft tissues, but no obvious signs of pleural effusion, pneumothorax, or pulmonary edema.
Plain scan CT examination (enhanced CT was not performed due to renal insufficiency) showed diffuse mediastinal emphysema, with gas extended to the upper chest and neck on both sides, with consolidation of the left lower lung and a small amount of pleural effusion on both sides (as shown in the figure below) .
Figure 1 Chest CT showed emphysema mediastinum and left pleural effusion about 12 hours after the onset of onset, upper gastrointestinal angiography revealed a perforation on the left side of the patient's distal esophagus, accompanied by leakage of contrast agent to the mediastinum, as shown in the following figure.
Figure 2 The upper gastrointestinal angiography shows the leakage of contrast agent outside the esophagus and around the left diaphragm.
The final diagnosis: Boerhaave syndrome.
Unfortunately, the patient still had persistent esophageal fistula after a series of emergency operations.
After the doctor provided informed consent for esophageal stent placement and conservative treatment, the patient chose conservative treatment.
After several weeks, the esophageal fistula gradually closed.
One month later, the gastroscope was rechecked and the result showed that the esophageal perforation was completely healed.
After 3 months, the patient resumed his normal diet and has returned to life on the road.
The clinical manifestations of Boerhaave syndrome Boerhaave syndrome is also known as spontaneous esophageal rupture.
The main pathogenesis is the sudden increase in internal pressure of the esophagus and the esophagus ruptures.
In 1724, Dutch physician Hermann Boerhaave described this rare but fatal disease for the first time.
Up to 96% of ultra-long-distance runners will experience gastrointestinal discomfort during the competition, but there is no related report of Boerhaave syndrome related to it in the literature.
Boerhaave syndrome is more common in men than women, and it usually affects men who drink and overeating in their 40s to 60s.
Only 5% of Boerhaave syndrome occurs in healthy people with no underlying cause, and other patients may develop on the basis of esophagitis or esophageal ulcer.
The most common manifestation of patients with Boerhaave syndrome is severe chest pain after severe vomiting.
Some patients may have the Mackler triad, that is, vomiting, chest pain, and subcutaneous emphysema.
In addition to vomiting, other causes include weightlifting, defecation, seizures, abdominal trauma, and childbirth.
These factors may increase the pressure in the esophagus.
Esophageal rupture usually occurs on the left side of the distal third of the esophagus.
Other symptoms include difficulty breathing, changes in voice, difficulty swallowing, and emphysema under the skin.
Diagnosis and differential diagnosis of Boerhaave syndrome 81%-90% of patients with Boerhaave syndrome have abnormal chest radiographs.
The latter helps to confirm the diagnosis.
However, within 6 hours after perforation of the esophagus, 10-33% of patients have normal chest radiographs.
The use of water-soluble contrast agents for upper gastrointestinal imaging is a powerful weapon for diagnosis.
Although barium is more advantageous in showing small perforations, barium extravasation can cause mediastinitis and fibrosis, so barium imaging is not recommended.
Enhanced CT is more sensitive to diagnosis than upper gastrointestinal angiography.
Although the sensitivity of the esophagoscope is close to 100%, the injection of gas during the examination may cause the tear to increase and further aggravate the perforation of the esophagus.
It should be used with caution.
In terms of differential diagnosis, clinical diagnosis is mainly based on acute sudden severe chest pain or upper abdominal pain, including acute myocardial infarction, rib fracture, pneumothorax, pulmonary embolism, ruptured aortic aneurysm, aortic aneurysm dissection, diaphragm rupture, acute pancreatitis, digestion Sexual ulcers with perforation and so on.
Treatment of Boerhaave Syndrome In the past, the mortality rate of Boerhaave syndrome patients was as high as 80%.
It was not until the report of successful surgical treatment of Boerhaave syndrome in 1947 that the mortality rate of this disease was significantly reduced to 2%-20%.
Esophageal perforation diagnosed within 12-24 hours after the onset of illness has the best prognosis.
However, when the diagnosis time was delayed to 24 hours after the onset, the mortality rate doubled.
Therefore, early recognition and diagnosis is the key to early treatment of patients, and early diagnosis has a better prognosis.
Initial treatment includes fluid resuscitation, intravenous antibiotics and/or antifungal drugs.
In addition to surgical operation as a radical cure, new treatments such as endoscopic implantation of esophageal stents, esophageal forceps, and gel repair of esophageal ruptures have great potential.
In summary, Boerhaave syndrome is a spontaneous esophageal rupture mainly induced by severe vomiting.
Although this disease is relatively rare, it can bring a fatal blow to patients.
Early diagnosis and early treatment are conducive to improving the prognosis of patients.
References: [1]Pasternak A, Ellero J, Maxwell S, Cheung V.
Boerhaave's syndrome in an ultra-distance runner.
BMJ Case Rep.
2019 Aug 8;12(8):e230343.
doi: 10.
1136/bcr-2019- 230343.
PMID: 31399415; PMCID: PMC6700565.
[2] Stuempfle KJ, Hoffman MD.
Gastrointestinal distress is common during a 161-km ultramarathon.
J Sports Sci 2015;0414:1–8.
[3] Rokicki M, Rokicki W, Rydel M.
Boerhaave's syndrome- over 290 years of surgical experiences, epidemiology, pathophysiology, dIagnosis.
Pol Przedglad Chiruggiczny 2016;88:359–64.
[4] Brauer RB, Liebermann-Meffert D, Stein HJ, et al.
Boerhaave's syndrome: analysis of the literature and report of 18 new cases.
Dis Esophagus 1997;10:64–8.
[5] Chirica M, Champault A, Dray X, et al.
Esophageal perforations.
J Visc Surg 2010;147:e117–28.
[6] Brinster CJ, Singhal S, Lee L, et al.
Evolving options in the management of esophageal perforation.
Ann Thorac Surg 2004;77:1475–83.
[7] Turner AR, Turner SD.
Boerhaave Syndrome.
[Updated 2021 Jan 1].
In: StatPearls [Internet].
Treasure Island (FL .
): StatPearls Publishing; 2021 Jan- article source: medical emergency and intensive channel author: CHENG KT editor: Monet Imprint original article forwarded welcome circle of friends - End -
Cardiovascular disease is a common cause of chest pain after long-distance running.
However, for the ultra-long-distance runner reported by Pasternak A et al.
in the BMJ Case Rep magazine, the cause of sudden chest pain may surprise you.
Case introduction This is a 37-year-old male athlete who participated in a 100-mile ultramarathon for the first time.
After a long journey, after leaving the permanent rescue station for a few hundred meters, the athlete was about to swallow an over-the-counter non-steroidal anti-inflammatory drug for temporary pain relief.
The patient suddenly developed nausea, vomiting, and eventually The medicine spit out.
However, when vomiting, the patient had sudden severe left chest pain and right upper abdominal pain, accompanied by difficulty breathing.
The patient feels pain similar to that of a rib fracture, and lying on his back can significantly worsen his chest pain.
The patient’s vital signs measured by the medical staff at the rescue station were normal, and the blood oxygen saturation was 95%.
Medical staff activated emergency medical services and rushed the patient to the nearest emergency room.
The emergency doctor rechecked the vital signs as: breathing 22 times/min, pulse rate 77 times/min, blood oxygen saturation 93%.
There was no abnormality in the electrocardiogram.
Blood test: white blood cell count rose to 17.
8 × 109/L, with neutrophil nucleus shifting to the left.
Urea nitrogen and creatinine increased to 50 mg/dl, 203.
3 μmol/l, CK 5349U/L, and BNP slightly increased to 614 pg/dL.
Troponin I slightly increased to 0.
09 ng/mL, and d-dimer increased to 598 ng/mL (returned to normal at the hospital review). Imaging examination: chest radiograph showed large infiltrates of the left lung floor, accompanied by mediastinal emphysema and scattered air in the soft tissues, but no obvious signs of pleural effusion, pneumothorax, or pulmonary edema.
Plain scan CT examination (enhanced CT was not performed due to renal insufficiency) showed diffuse mediastinal emphysema, with gas extended to the upper chest and neck on both sides, with consolidation of the left lower lung and a small amount of pleural effusion on both sides (as shown in the figure below) .
Figure 1 Chest CT showed emphysema mediastinum and left pleural effusion about 12 hours after the onset of onset, upper gastrointestinal angiography revealed a perforation on the left side of the patient's distal esophagus, accompanied by leakage of contrast agent to the mediastinum, as shown in the following figure.
Figure 2 The upper gastrointestinal angiography shows the leakage of contrast agent outside the esophagus and around the left diaphragm.
The final diagnosis: Boerhaave syndrome.
Unfortunately, the patient still had persistent esophageal fistula after a series of emergency operations.
After the doctor provided informed consent for esophageal stent placement and conservative treatment, the patient chose conservative treatment.
After several weeks, the esophageal fistula gradually closed.
One month later, the gastroscope was rechecked and the result showed that the esophageal perforation was completely healed.
After 3 months, the patient resumed his normal diet and has returned to life on the road.
The clinical manifestations of Boerhaave syndrome Boerhaave syndrome is also known as spontaneous esophageal rupture.
The main pathogenesis is the sudden increase in internal pressure of the esophagus and the esophagus ruptures.
In 1724, Dutch physician Hermann Boerhaave described this rare but fatal disease for the first time.
Up to 96% of ultra-long-distance runners will experience gastrointestinal discomfort during the competition, but there is no related report of Boerhaave syndrome related to it in the literature.
Boerhaave syndrome is more common in men than women, and it usually affects men who drink and overeating in their 40s to 60s.
Only 5% of Boerhaave syndrome occurs in healthy people with no underlying cause, and other patients may develop on the basis of esophagitis or esophageal ulcer.
The most common manifestation of patients with Boerhaave syndrome is severe chest pain after severe vomiting.
Some patients may have the Mackler triad, that is, vomiting, chest pain, and subcutaneous emphysema.
In addition to vomiting, other causes include weightlifting, defecation, seizures, abdominal trauma, and childbirth.
These factors may increase the pressure in the esophagus.
Esophageal rupture usually occurs on the left side of the distal third of the esophagus.
Other symptoms include difficulty breathing, changes in voice, difficulty swallowing, and emphysema under the skin.
Diagnosis and differential diagnosis of Boerhaave syndrome 81%-90% of patients with Boerhaave syndrome have abnormal chest radiographs.
The latter helps to confirm the diagnosis.
However, within 6 hours after perforation of the esophagus, 10-33% of patients have normal chest radiographs.
The use of water-soluble contrast agents for upper gastrointestinal imaging is a powerful weapon for diagnosis.
Although barium is more advantageous in showing small perforations, barium extravasation can cause mediastinitis and fibrosis, so barium imaging is not recommended.
Enhanced CT is more sensitive to diagnosis than upper gastrointestinal angiography.
Although the sensitivity of the esophagoscope is close to 100%, the injection of gas during the examination may cause the tear to increase and further aggravate the perforation of the esophagus.
It should be used with caution.
In terms of differential diagnosis, clinical diagnosis is mainly based on acute sudden severe chest pain or upper abdominal pain, including acute myocardial infarction, rib fracture, pneumothorax, pulmonary embolism, ruptured aortic aneurysm, aortic aneurysm dissection, diaphragm rupture, acute pancreatitis, digestion Sexual ulcers with perforation and so on.
Treatment of Boerhaave Syndrome In the past, the mortality rate of Boerhaave syndrome patients was as high as 80%.
It was not until the report of successful surgical treatment of Boerhaave syndrome in 1947 that the mortality rate of this disease was significantly reduced to 2%-20%.
Esophageal perforation diagnosed within 12-24 hours after the onset of illness has the best prognosis.
However, when the diagnosis time was delayed to 24 hours after the onset, the mortality rate doubled.
Therefore, early recognition and diagnosis is the key to early treatment of patients, and early diagnosis has a better prognosis.
Initial treatment includes fluid resuscitation, intravenous antibiotics and/or antifungal drugs.
In addition to surgical operation as a radical cure, new treatments such as endoscopic implantation of esophageal stents, esophageal forceps, and gel repair of esophageal ruptures have great potential.
In summary, Boerhaave syndrome is a spontaneous esophageal rupture mainly induced by severe vomiting.
Although this disease is relatively rare, it can bring a fatal blow to patients.
Early diagnosis and early treatment are conducive to improving the prognosis of patients.
References: [1]Pasternak A, Ellero J, Maxwell S, Cheung V.
Boerhaave's syndrome in an ultra-distance runner.
BMJ Case Rep.
2019 Aug 8;12(8):e230343.
doi: 10.
1136/bcr-2019- 230343.
PMID: 31399415; PMCID: PMC6700565.
[2] Stuempfle KJ, Hoffman MD.
Gastrointestinal distress is common during a 161-km ultramarathon.
J Sports Sci 2015;0414:1–8.
[3] Rokicki M, Rokicki W, Rydel M.
Boerhaave's syndrome- over 290 years of surgical experiences, epidemiology, pathophysiology, dIagnosis.
Pol Przedglad Chiruggiczny 2016;88:359–64.
[4] Brauer RB, Liebermann-Meffert D, Stein HJ, et al.
Boerhaave's syndrome: analysis of the literature and report of 18 new cases.
Dis Esophagus 1997;10:64–8.
[5] Chirica M, Champault A, Dray X, et al.
Esophageal perforations.
J Visc Surg 2010;147:e117–28.
[6] Brinster CJ, Singhal S, Lee L, et al.
Evolving options in the management of esophageal perforation.
Ann Thorac Surg 2004;77:1475–83.
[7] Turner AR, Turner SD.
Boerhaave Syndrome.
[Updated 2021 Jan 1].
In: StatPearls [Internet].
Treasure Island (FL .
): StatPearls Publishing; 2021 Jan- article source: medical emergency and intensive channel author: CHENG KT editor: Monet Imprint original article forwarded welcome circle of friends - End -
