Boerhaave Syndrome With Alkaline Pleural Effusion

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Boerhaave Syndrome With Alkaline Pleural Effusion

• Kelechi Okoli, MD
• Vamsee Marina, MD
• Hussam Elkambergy, MD
• Geetali Mohan, MD
• Veejay Mahajan, MD

OHIO THORACIC SOCIETY 57TH ANNUAL CONFERENCE 7 -
8 SEPTEMBER, 2007
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Pleural Fluid pH in Esophageal Rupture

• Gastric acid reflux1?
• Bacterial metabolism?
• Neutrophil metabolism2?
• Only elimination of neutrophils prevented fall in
  pH in experimental esophageal rupture

1. Abbott OA, Mansour KA, Logan WD, et al
   Atraumatic so-called "spontaneous" rupture of the
   esophagus. J Thorac Cardiovasc Surg 596742, 1970
2. Good JT Jr, Antony VB, Reller LB, Maulitz RM,
   Sahn SA. The pathogenesis of the low pleural
   fluid pH in esophageal rupture. Am Rev Respir
   Dis. 1983 Jun127(6)702-4

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HPI

• 41 year-old type 1 diabetic
• Two days of nausea and vomiting
• PMH ESRD, CVA, PE
• Uremia. Hyperkalemia. DKA
• Hemodialysis and insulin
• Resolution of clinical and biochemical
  abnormalities

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HPI

• On fifth hospital day, he vomited
• Acute dyspnea
• BP 89/30mmHg HR 128/min RR 34/min SaO2 83
  Temp 36.6oC
• Absent breath sounds over left hemithorax
• Portable CXR obtained

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Intervention

• Left tube thoracostomy
• Left lung re-expansion
• Persistent air leak
• Non-ionic contrast esophagogram

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Pleural Fluid

• pH 7.51
• LDH 184 IU/L
• Protein 2.8 g/dL
• Amylase 2400 U/L
• No WBC seen
• Oral flora, Klebsiella, Haemophilus

Blood . pH 7.28 . LDH 196 IU/L . Protein
3.9 g/dL . WBC 17.8 x 109
1. Corning pH meter
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Outcome

• Left thoracotomy and decortication
• 2cm perforation in left posterolateral esophageal
  wall 3cm proximal to EGJ
• Complicated post-operative course
• Ventilator dependent
• Expired in palliative medicine unit

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Conclusion

• Current case supports neutrophil metabolism
• Temporal relationship between symptom onset and
  pleural fluid sampling should be considered when
  esophageal rupture is suspected

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Abstract