CASE REPORT
Boerhaave Syndrome Resulting From Homicidal Blunt Trauma Michelle Xia, MD*Þ and Stephen Pustilnik, MD*Þ
Abstract: Boerhaave syndrome is an uncommon condition with high rate of mortality that is higher than 90%. The syndrome has classically been associated with sudden severe chest pain after severe emesis or retching. However, traumatic esophageal rupture secondary to blunt injury has been occasionally reported in the literature, usually from unintentional injury. We report the first case of Boerhaave syndrome resulting from homicidally inflicted blunt trauma to the abdomen, which is a rare finding that can be easily missed during an autopsy. Key Words: Boerhaave, esophageal rupture, esophageal perforation, blunt trauma, homicide, assault, abdominal trauma, blow to abdomen, inflicted (Am J Forensic Med Pathol 2014;35: 176Y177)
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oerhaave syndrome was first described by Dr Herman Boerhaave in 1724 in a case report of a baron who had a habit of eating large meals. In the narrative, after he consumed a particular abundant meal, the baron had episodes of vomiting as well as retching associated with subsequent esophageal rupture and development of septic mediastinitis that proved to be fatal. An autopsy was performed, which showed a tear in the left posterior esophagus.1 Since then, Boerhaave syndrome has been known as a relatively uncommon condition but with a high rate of mortality that is higher than 90%.2 The fatality is often caused by development of mediastinal sepsis from contamination with gastroesophageal contents such as bacteria as well as gastric and salivary fluids. The victims, most of the time, present with nonspecific findings such as severe pain in the chest and epigastrium, dyspnea, vomiting, tachycardia, as well as possible signs of shock. The Meckler triad, a set of typical symptoms consisting of pain in the left side of the chest, vomiting, and subcutaneous emphysema, is only present in 30% to 50% of cases.3 It is more frequently seen in males with a ratio of 5:1 and more common during the fourth to fifth decades, although cases have been reported in all age groups.4 The syndrome has classically been associated with sudden severe chest pain after severe emesis or retching.5 The typical example is an otherwise healthy, alcohol abuser with severe vomiting and retching after an episode of intoxication, rupturing his esophagus. However, traumatic esophageal rupture secondary to blunt injury has been rarely reported in the literature. The most common cause of traumatic blunt injury esophageal rupture is a motor vehicle crash.6Y8 In addition, cases involving motor-pedestrian accident,8 fall from window,9 and crush injuries from falling objects10 can be found in the literature. Manuscript received October 22, 2013; accepted December 1, 2013. *Department of Pathology, University of Texas Medical Branch, Galveston, TX; and †South Coast Forensics, LLC. The authors report no conflicts of interest. Reprints: Stephen Pustilnik, MD, 5739 Ariel St, Houston, TX 77096. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0195-7910/14/3503Y0176 DOI: 10.1097/PAF.0000000000000102
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We report a case of a 39-year-old white man with traumatic rupture of the esophagus from inflicted blunt trauma to the abdomen after a fight at a bar. The internal and external forensic findings are discussed.
FINDINGS A 39-year-old white man with a medical history significant for alcohol abuse was involved in a gang-related fight at a bar and was found by his girlfriend prostrated in the front yard of his residence. He was moved into the residence where he remained delirious for the next 30 hours. He was found dead inside the residence approximately 40 minutes after last being seen alive. Externally, the deceased had bruising to the left buccal mucosa and left brow ridge as well as left occipital subgaleal hemorrhage. Internally, he had bilateral frontal subdural and subarachnoid hemorrhages, bilateral anterior temporal contusions, as well as deep white matter and basal ganglia contusions. In the left hemithorax was 800 mL of brown bloody fluid with a prominent acidic aroma. This was associated with traumatic rupture of the gastroesophageal junction on the left side with softening and digestion of the lower lobe of the left lung and the lower portion of the esophagus with associated posterior mediastinal hemorrhage (Figs. 1, 2).
DISCUSSION We performed an online Medical Subject Headings (MeSH) literature search on PubMed dating back to 1966 for the following terms individually and in combination: ‘‘Boerhaave,’’ ‘‘esophageal rupture,’’ ‘‘esophageal perforation,’’ ‘‘blunt trauma,’’ ‘‘homicide,’’ ‘‘assault,’’ ‘‘abdominal trauma,’’ ‘‘blow to abdomen,’’ and ‘‘inflicted.’’ To the best of our knowledge, this is the first case of Boerhaave syndrome resulting from homicidally inflicted blunt trauma to the abdomen in an adult.
FIGURE 1. In situ photograph demonstrating autolysis from gastric acid in the left hemithorax, with exposure of the structures of the posterior mediastinum and esophagus. Extensive erythema and pleural hemorrhage are also visible. Am J Forensic Med Pathol
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Volume 35, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Am J Forensic Med Pathol
&
Volume 35, Number 3, September 2014
Boerhaave Syndrome From Homicidal Blunt Trauma
junction rupture with subsequent hemothorax and acidic pneumolysis. The tear was found on the lower third of the esophagus, which is consistent with the typical location of tears found in Boerhaave syndrome. This is the first reported case of homicidal Boerhaave syndrome, which is a rare finding that can be easily missed during an autopsy. REFERENCES 1. Boerhaave H. Atrocis, nec descripti prius, morbid historia. Secundum medicae artis leges conscripta. Lugduni Batavorum Boutesteniana, 1724. Translation by Derbes VJ, Mitchell RE Jr. Bull Med Libr Assoc. 1955;43:217Y240. 2. Cle´ment R, Bresson C, Rodat O. Spontaneous oesophageal perforation. J Clin Forensic Med. 2006;13:353Y355.
FIGURE 2. Site of rupture and autolytic digestion of the esophagus.
Boerhaave syndrome is known to occur mainly in the left lateral wall of the distal portion of the esophagus. The cause of a spontaneous rupture is an increase in intraluminal esophageal pressure. The first experiment was done in 1884 when Mackenzie11 tied the distal end of the esophagus from cadavers and studied this pathology by insufflated water into the esophageal lumen. His experiment showed that, in 17 of 18 cases, after applying an average of 7 psi of pressure, the split was longitudinal, occurred at the lower end of the esophagus just above the cardia, and varied in length between 1 and 5 cm. Years later, Mackler12 in 1952 and Bodi et al13 in 1954 elicited similar experimental results, confirming Mackenzie’s findings.11 Duval and Burt14 showed that, in addition to the pressure applied, the rapidity of increase in pressure is also a factor in the rupture of the gastrointestinal walls. In the experiment, the average pressure needed to cause rupture was lower with rapid introduction of air compared with slow introduction of air into the lumen. In this case presentation, the blow(s) to the abdomen caused the rapid increase in the intra-abdominal pressure. This was translated to a rapid increase in the intraluminal pressure in the stomach resulting in rupture. A recent study in 2007 further contributed to this knowledge by showing that the tears usually occur in a weak point in the wall, usually in the connective tissue of the junction between clasp and oblique fibers in the lower third of the esophagus.15 Our patient was assaulted in a bar with blunt force trauma to his head and abdomen. The increased abdominal pressure from the inflicted blows led to a rapid increase in the intra-abdominal pressure. This sudden increased pressure resulted in gastroesophageal
* 2014 Lippincott Williams & Wilkins
3. Szeliga J, Jackowski M. Boerhaave syndrome. Pol Przegl Chir. 2011;83(9):523Y526. 4. Panaro VA, Leslie ES. Spontaneous rupture of the esophagus. Radiology. 1965;84:252Y257. 5. Phelan HA, Brakenridge SC, Rutland TJ, et al. Boerhaave syndrome presenting as massive hemothorax. South Med J. 2009;102(2):202Y203. 6. Monzon JR, Ryan B. Thoracic esophageal perforation secondary to blunt trauma. J Trauma. 2000;49:1129Y1131. 7. Bernard AW, Ben-David K, Pritts T. Delayed presentation of thoracic esophageal perforation after blunt trauma. J Emerg Med. 2008;34(1): 49Y53. 8. Cordero JA, Kuehler DH, Fortune JB. Distal esophageal rupture after external blunt trauma: report of two cases. J Trauma. 1997;42:321Y322. 9. Strauss DC, Tandon R, Mason RC. Distal thoracic oesophageal perforation secondary to blunt trauma: case report. World J Emerg Surg. 2007;2:8. 10. Sartorelli KH, McBride WJ, Vane DW. Perforation of the intrathoracic esophagus from blunt trauma in a child: case report and review of the literature. J Pediatr Surg. 1999;34(3):495Y497. 11. Mackenzie MA. Manual of Disease of the Ear, Nose and Throat. New York, NY: Wm Wood & Co; 1880;113Y114. 12. Mackler SA. Spontaneous rupture of the esophagus; an experimental and clinical study. Surg Gynecol Obstet. 1952;95:345Y356. 13. Bodi T, Fanger H, Forsythe T. Spontaneous rupture of esophagus. Ann Intern Med. 1954;41:553Y562. 14. Duval P. Quoted by: Burt CA. Pneumatic rupture of the intestinal canal with experimental data showing the mechanism of perforation and the pressure required. Arch Surg. 1931;22:875Y902. 15. Korn O, On˜ate JC, Lo´pez R. Anatomy of the Boerhaave syndrome. Surgery. 2007;141(2):222Y228.
www.amjforensicmedicine.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
177
Boerhaave Syndrome Resulting From Homicidal Blunt Trauma Michelle Xia, MD*Þ and Stephen Pustilnik, MD*Þ
Abstract: Boerhaave syndrome is an uncommon condition with high rate of mortality that is higher than 90%. The syndrome has classically been associated with sudden severe chest pain after severe emesis or retching. However, traumatic esophageal rupture secondary to blunt injury has been occasionally reported in the literature, usually from unintentional injury. We report the first case of Boerhaave syndrome resulting from homicidally inflicted blunt trauma to the abdomen, which is a rare finding that can be easily missed during an autopsy. Key Words: Boerhaave, esophageal rupture, esophageal perforation, blunt trauma, homicide, assault, abdominal trauma, blow to abdomen, inflicted (Am J Forensic Med Pathol 2014;35: 176Y177)
B
oerhaave syndrome was first described by Dr Herman Boerhaave in 1724 in a case report of a baron who had a habit of eating large meals. In the narrative, after he consumed a particular abundant meal, the baron had episodes of vomiting as well as retching associated with subsequent esophageal rupture and development of septic mediastinitis that proved to be fatal. An autopsy was performed, which showed a tear in the left posterior esophagus.1 Since then, Boerhaave syndrome has been known as a relatively uncommon condition but with a high rate of mortality that is higher than 90%.2 The fatality is often caused by development of mediastinal sepsis from contamination with gastroesophageal contents such as bacteria as well as gastric and salivary fluids. The victims, most of the time, present with nonspecific findings such as severe pain in the chest and epigastrium, dyspnea, vomiting, tachycardia, as well as possible signs of shock. The Meckler triad, a set of typical symptoms consisting of pain in the left side of the chest, vomiting, and subcutaneous emphysema, is only present in 30% to 50% of cases.3 It is more frequently seen in males with a ratio of 5:1 and more common during the fourth to fifth decades, although cases have been reported in all age groups.4 The syndrome has classically been associated with sudden severe chest pain after severe emesis or retching.5 The typical example is an otherwise healthy, alcohol abuser with severe vomiting and retching after an episode of intoxication, rupturing his esophagus. However, traumatic esophageal rupture secondary to blunt injury has been rarely reported in the literature. The most common cause of traumatic blunt injury esophageal rupture is a motor vehicle crash.6Y8 In addition, cases involving motor-pedestrian accident,8 fall from window,9 and crush injuries from falling objects10 can be found in the literature. Manuscript received October 22, 2013; accepted December 1, 2013. *Department of Pathology, University of Texas Medical Branch, Galveston, TX; and †South Coast Forensics, LLC. The authors report no conflicts of interest. Reprints: Stephen Pustilnik, MD, 5739 Ariel St, Houston, TX 77096. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0195-7910/14/3503Y0176 DOI: 10.1097/PAF.0000000000000102
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www.amjforensicmedicine.com
We report a case of a 39-year-old white man with traumatic rupture of the esophagus from inflicted blunt trauma to the abdomen after a fight at a bar. The internal and external forensic findings are discussed.
FINDINGS A 39-year-old white man with a medical history significant for alcohol abuse was involved in a gang-related fight at a bar and was found by his girlfriend prostrated in the front yard of his residence. He was moved into the residence where he remained delirious for the next 30 hours. He was found dead inside the residence approximately 40 minutes after last being seen alive. Externally, the deceased had bruising to the left buccal mucosa and left brow ridge as well as left occipital subgaleal hemorrhage. Internally, he had bilateral frontal subdural and subarachnoid hemorrhages, bilateral anterior temporal contusions, as well as deep white matter and basal ganglia contusions. In the left hemithorax was 800 mL of brown bloody fluid with a prominent acidic aroma. This was associated with traumatic rupture of the gastroesophageal junction on the left side with softening and digestion of the lower lobe of the left lung and the lower portion of the esophagus with associated posterior mediastinal hemorrhage (Figs. 1, 2).
DISCUSSION We performed an online Medical Subject Headings (MeSH) literature search on PubMed dating back to 1966 for the following terms individually and in combination: ‘‘Boerhaave,’’ ‘‘esophageal rupture,’’ ‘‘esophageal perforation,’’ ‘‘blunt trauma,’’ ‘‘homicide,’’ ‘‘assault,’’ ‘‘abdominal trauma,’’ ‘‘blow to abdomen,’’ and ‘‘inflicted.’’ To the best of our knowledge, this is the first case of Boerhaave syndrome resulting from homicidally inflicted blunt trauma to the abdomen in an adult.
FIGURE 1. In situ photograph demonstrating autolysis from gastric acid in the left hemithorax, with exposure of the structures of the posterior mediastinum and esophagus. Extensive erythema and pleural hemorrhage are also visible. Am J Forensic Med Pathol
&
Volume 35, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Am J Forensic Med Pathol
&
Volume 35, Number 3, September 2014
Boerhaave Syndrome From Homicidal Blunt Trauma
junction rupture with subsequent hemothorax and acidic pneumolysis. The tear was found on the lower third of the esophagus, which is consistent with the typical location of tears found in Boerhaave syndrome. This is the first reported case of homicidal Boerhaave syndrome, which is a rare finding that can be easily missed during an autopsy. REFERENCES 1. Boerhaave H. Atrocis, nec descripti prius, morbid historia. Secundum medicae artis leges conscripta. Lugduni Batavorum Boutesteniana, 1724. Translation by Derbes VJ, Mitchell RE Jr. Bull Med Libr Assoc. 1955;43:217Y240. 2. Cle´ment R, Bresson C, Rodat O. Spontaneous oesophageal perforation. J Clin Forensic Med. 2006;13:353Y355.
FIGURE 2. Site of rupture and autolytic digestion of the esophagus.
Boerhaave syndrome is known to occur mainly in the left lateral wall of the distal portion of the esophagus. The cause of a spontaneous rupture is an increase in intraluminal esophageal pressure. The first experiment was done in 1884 when Mackenzie11 tied the distal end of the esophagus from cadavers and studied this pathology by insufflated water into the esophageal lumen. His experiment showed that, in 17 of 18 cases, after applying an average of 7 psi of pressure, the split was longitudinal, occurred at the lower end of the esophagus just above the cardia, and varied in length between 1 and 5 cm. Years later, Mackler12 in 1952 and Bodi et al13 in 1954 elicited similar experimental results, confirming Mackenzie’s findings.11 Duval and Burt14 showed that, in addition to the pressure applied, the rapidity of increase in pressure is also a factor in the rupture of the gastrointestinal walls. In the experiment, the average pressure needed to cause rupture was lower with rapid introduction of air compared with slow introduction of air into the lumen. In this case presentation, the blow(s) to the abdomen caused the rapid increase in the intra-abdominal pressure. This was translated to a rapid increase in the intraluminal pressure in the stomach resulting in rupture. A recent study in 2007 further contributed to this knowledge by showing that the tears usually occur in a weak point in the wall, usually in the connective tissue of the junction between clasp and oblique fibers in the lower third of the esophagus.15 Our patient was assaulted in a bar with blunt force trauma to his head and abdomen. The increased abdominal pressure from the inflicted blows led to a rapid increase in the intra-abdominal pressure. This sudden increased pressure resulted in gastroesophageal
* 2014 Lippincott Williams & Wilkins
3. Szeliga J, Jackowski M. Boerhaave syndrome. Pol Przegl Chir. 2011;83(9):523Y526. 4. Panaro VA, Leslie ES. Spontaneous rupture of the esophagus. Radiology. 1965;84:252Y257. 5. Phelan HA, Brakenridge SC, Rutland TJ, et al. Boerhaave syndrome presenting as massive hemothorax. South Med J. 2009;102(2):202Y203. 6. Monzon JR, Ryan B. Thoracic esophageal perforation secondary to blunt trauma. J Trauma. 2000;49:1129Y1131. 7. Bernard AW, Ben-David K, Pritts T. Delayed presentation of thoracic esophageal perforation after blunt trauma. J Emerg Med. 2008;34(1): 49Y53. 8. Cordero JA, Kuehler DH, Fortune JB. Distal esophageal rupture after external blunt trauma: report of two cases. J Trauma. 1997;42:321Y322. 9. Strauss DC, Tandon R, Mason RC. Distal thoracic oesophageal perforation secondary to blunt trauma: case report. World J Emerg Surg. 2007;2:8. 10. Sartorelli KH, McBride WJ, Vane DW. Perforation of the intrathoracic esophagus from blunt trauma in a child: case report and review of the literature. J Pediatr Surg. 1999;34(3):495Y497. 11. Mackenzie MA. Manual of Disease of the Ear, Nose and Throat. New York, NY: Wm Wood & Co; 1880;113Y114. 12. Mackler SA. Spontaneous rupture of the esophagus; an experimental and clinical study. Surg Gynecol Obstet. 1952;95:345Y356. 13. Bodi T, Fanger H, Forsythe T. Spontaneous rupture of esophagus. Ann Intern Med. 1954;41:553Y562. 14. Duval P. Quoted by: Burt CA. Pneumatic rupture of the intestinal canal with experimental data showing the mechanism of perforation and the pressure required. Arch Surg. 1931;22:875Y902. 15. Korn O, On˜ate JC, Lo´pez R. Anatomy of the Boerhaave syndrome. Surgery. 2007;141(2):222Y228.
www.amjforensicmedicine.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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