Diagnostic challenges in boerhaave syndrome with bilateral pleural contamination: complementary roles of computed tomography, endoscopy, and video-assisted thoracoscopic surgery.

BACKGROUND: Boerhaave syndrome is a rare but life-threatening condition due to spontaneous transmural perforation of the esophagus, which most often occurs after copious vomiting. Late diagnosis may lead to mediastinitis, empyema, septicemia, and even death. Localization of the perforation is sometimes difficult despite computed tomography (CT) being regarded as the cornerstone in diagnosis. METHODS: A 36-year-old male Chinese patient presented with acute chest pain following recurrent attacks of violent vomiting due to excessive amount of drinking. On clinical examination, tachypnea, fever, tachycardia, and respiratory distress were observed. Laboratory tests showed significant neutrophilic leukocytosis, raised C-reactive protein and type 2 respiratory failure. Bilateral pleural effusions and pneumomediastinum were seen on contrast-enhanced chest CT, indicative of Boerhaave syndrome. Emergency video-assisted thoracoscopic surgery (VATS), with pleural debridement, drainage, nutritional and intensive care management, was performed. Eventually, an esophageal perforation in the left distal esophageal wall was seen during esophagogastroscopy, revealing the lack of correlation between the distribution of pleural contamination and the site of the perforation. Additional thoracoscopic debridement and multidisciplinary management resulted in progressive recovery. CONCLUSION: Boerhaave syndrome is a diagnostic challenge, and radiographic findings do not always reveal the exact site of esophageal perforation. The use of CT, endoscopic evaluation and VATS offered complementary diagnostic and therapeutic benefits, facilitating the proper localization, source control and clinical recovery. Multidisciplinary treatment is key to maximizing the prognosis in the early treatment of this fatal disorder.