SPONTANEOUS RUPTURE OF ESO-PHAGUS (CASE REPORT)

Spontaneous rupture of esophagus, also well-known as Boerhaave syndrome (BS), was described in 1724 by Herman Boerhaave. [1,2] It is a rare, complex and life-threatening disease causing severe complications with subsequent development of sepsis, respiratory failure and should be diagnosed and treated urgently, because of high mortality. [3, 4] Pathomorphological changes of BS are mainly described during the operation so include only macroscopic study. [4-6] Histological changes in tissues and organs are reviewed in some articles. [7] High level of negative outcomes and mortality in addition to the lack of awareness among doctors determines the relevance of our investigation. This article presents lethal case of spontaneous rupture of esophagus with subsequent autopsy and histological investigation of sectional material by microscope. А 79-year-old woman was rushed to a hospital in critical condition 11 hours after the episode of vomiting accompanied by chest pain and face edema with dyspnea, weakness and dry mouth. The act of vomiting followed an intranasal using of vasoconstrictor drops. Physical examina-tion revealed subcutaneous emphysema and signs of hydro pneumothorax confirmed by radiographic examination and pleural puncture based on which BS was diagnosed. Despite intensive therapy, the respiratory failure developed, requiring mechanical ventilation support and the patient died 50 minutes after hospitalization. The following changes were found on the section: subcutaneous emphysema, plural effusion in the thoracic cavity with food residue, pleurisy and collapse of the left lung, pneumonia, mediastinitis and the sings of acute renal failure. The rupture of the esophagus length of 3 cm was located in the distal part of esophagus on the left side. All this changes were confirmed with microscopy. Esophageal mucosa was detached from tunica media and characterized by inflammation, necrosis and hemorrhages. Histological feature of the esophageal media was the muscular contractures. BS is a condition with the possibility of an errone-ous diagnosis. [4, 8] The most common symptom of esopha-gus rupture (we also diagnosed it in our case) is Mackler's triad of chest pain following an episode of vomiting or retch-ing and subcutaneous emphysema [6, 8-10] but, as has been proved, not in all cases. [4] BS typically occurs in conjunction with swallowing a large food bolus [3, 9, and 11] alcohol consumption [10-12] fizzy drink. [12] In our case it seems to be connected with vasoconstrictor drops. Clinical symptoms of BS such as pleural effusion and subcutaneous emphysema, pneumomediastinum, hydropneumothorax, lung collapse [5, 11] that are similar to ours, can be identified by radiographic examination. [2, 8, 10] Many patients developed respiratory failure [8] or septic shock. [4-7] We don't have much infor-mation about our patientʼs comorbidities but there have been established some diseases in other articles: esophagitis, gastro-esophageal reflux disease, peptic ulcer disease [3,4,13] Barrett's esophagus. [8] The rupture length of 1-6 cm [2,5,8,9,12] is located in the lower esophagus on the left side. [1,2,4,8] This is believed to be due to anatomic weakness. [8] The contraction of muscles is appeared due to an increasing of intra-esophageal pressure [2,13] without muscle relaxation of the gastro-esophageal junction. [14] Іt proves the spontaneous etiology of the esophageal rupture. Taking into account everything mentioned above it can be concluded that BS is a severe disease with an unpre-dictable outcomes and own histological features.