{"id":2359,"date":"2025-03-27T17:00:13","date_gmt":"2025-03-27T21:00:13","guid":{"rendered":"https:\/\/wordpress.forensicpath.us\/?p=2359"},"modified":"2025-03-28T23:33:43","modified_gmt":"2025-03-29T03:33:43","slug":"pathology-cases-boerhaave-syndrome-spontaneous-esophageal-rupture","status":"publish","type":"post","link":"https:\/\/wordpress.forensicpath.us\/index.php\/2025\/03\/27\/pathology-cases-boerhaave-syndrome-spontaneous-esophageal-rupture\/","title":{"rendered":"Pathology cases — Boerhaave syndrome (spontaneous esophageal rupture)"},"content":{"rendered":"

This is a case of a 40-year-old man with a history of intravenous drug use found dead at home. It shows, among other things, the value of taking lots of pictures.<\/p>\n

At autopsy, he had a bunch of green discoloration of his upper abdomen and left chest. I wasn’t sure what the green stuff was when the chest plate was opened, so I took a photo of the chest and abdomen block before the autopsy assistant moved anything around. Turned out there were 200 cc of bile-stained gastric contents in the left chest and a distal esophageal tear.<\/p>\n

I assumed that the death was likely due to sudden cardiac death due to hypokalemia due to nausea and vomiting, which I have seen in the past. But no… I did a search on this and it turns out that spontaneous distal esophageal tears have a name (“Boerhaave syndrome”) with a stunningly high mortality, and the most common mechanism of rapid death is tension pneumothorax.\u00a0 \u00a0I’m sure I’d heard of this before, sometime in the past 40 years, but it had vanished into the mists of time.\u00a0 The other rapid deaths are sudden arrythmia due to vagal response, hemorrhage.\u00a0 On a more delayed basis, of course, would be sepsis.<\/p>\n

For those of you who are not pathologists, if you suspect a pneumothorax you can take a water-filled syringe with a long needle and penetrate the thoracic wall.\u00a0 If there’s air under pressure, air will move from the chest into the syringe and you can see bubbles.\u00a0 That’s the simple test for tension pneumothorax in a postmortem exam.\u00a0 Also, you can also see the air and displaced heart on xray.\u00a0 But… nobody needles the chest to do a bubble test routinely as far as I know, and I certainly didn’t. And, we don’t routinely x-ray these drug gases.<\/p>\n

Sigh.<\/p>\n

But, I went back to the photo that we took, and lo and behold, there’s a collapsed left lung and lots of extra empty pleural space, which I didn’t really recognize at the time.<\/p>\n

So here’s a diagnostic photo taken not-quite-on-a-whim that turned out to be important on review.\u00a0 There’s a nice contrast with the right lung that isn’t collapsed:<\/p>\n

\"\"<\/a><\/p>\n

Here’s a pic of the serosal surface of the esophagus, covered with gastric contents:<\/p>\n

\"\"<\/a><\/p>\n

As an aside, he did not have any drugs on board.\u00a0 These are usually due to nausea and vomiting, and I don’t know why he was doing that unless it was drug withdrawal.\u00a0 The tears are usually distal and on the left, which is where this one was.<\/p>\n","protected":false},"excerpt":{"rendered":"

This is a case of a 40-year-old man with a history of intravenous drug use found dead at home. It…<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[108,109],"tags":[59,140,28],"class_list":["post-2359","post","type-post","status-publish","format-standard","hentry","category-gross-pathology","category-pathology-cases","tag-autopsy","tag-esophagus","tag-pathology"],"_links":{"self":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts\/2359","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/comments?post=2359"}],"version-history":[{"count":6,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts\/2359\/revisions"}],"predecessor-version":[{"id":2380,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts\/2359\/revisions\/2380"}],"wp:attachment":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/media?parent=2359"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/categories?post=2359"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/tags?post=2359"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}