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Boerhaave first described the spontaneous rupture of the esophagus in 1724. It typically occurs after forceful emesis. Boerhaave syndrome is a transmural perforation of the esophagus to be distinguished from mallory-weiss syndrome, a nontransmural esophageal tear also associated with vomiting. Because it often is associated with emesis, boerhaave syndrome usually is not truly spontaneous. However, the term is useful for distinguishing it from iatrogenic perforation, which accounts for 85-90% of cases of esophageal rupture.
Diagnosis of boerhaave syndrome can be difficult because often no classic symptoms are present and delays in presentation for medical care are common. Approximately one third of all cases of boerhaave syndrome are clinically atypical. Prompt recognition of this potentially lethal condition is vital to ensure appropriate treatment. Mediastinitis, sepsis, and shock frequently are seen late in the course of illness, which further confuses the diagnostic picture.
See can't-miss gastrointestinal diagnoses, a critical images slideshow, to help diagnose the potentially life-threatening conditions that present with gastrointestinal symptoms.
A reported mortality estimate is approximately 35%, making it the most lethal perforation of the gi tract. The best outcomes are associated with early diagnosis and definitive surgical management within 12 hours of rupture. If intervention is delayed longer than 24 hours, the mortality rate (even with surgical intervention) rises to higher than 50% and to nearly 90% after 48 hours. Left untreated, the mortality rate is close to 100%.
Esophageal rupture in boerhaave syndrome is postulated to be the result of a sudden rise in intraluminal esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of the cricopharyngeus muscle to relax. The syndrome commonly is associated with overindulgence in food and/or alcohol. The most common anatomical location of the tear in boerhaave syndrome is at the left posterolateral wall of the lower third of the esophagus, 2-3 cm proximal to the gastroesophageal junction, along the longitudinal wall of the esophagus. The second most common site of rupture is in the subdiaphragmatic or upper thoracic area. [1, 2]
Although likely underreported, the incidence of boerhaave syndrome is relatively rare. A 1980 review by kish cited 300 cases in the literature worldwide.  a 1986 summary by bladergroen et al described 127 cases.  of these, 114 were diagnosed antemortem; the others were diagnosed at autopsy. Overall, boerhaave syndrome accounts for 15% of all cases of traumatic rupture or perforation of the esophagus.
Race-, sex-, and age-related demographics
Cases have been reported in all races and on virtually every continent, affecting males more commonly than females, with ratios ranging from 2: 1 to 5: 1.
Boerhaave syndrome is seen most frequently among patients aged 50-70 years. Reports suggest that 80% of all patients are middle-aged men. However, this condiction has also been described in neonates and in persons older than 90 years. Although no clear explanation exists for this, the least susceptible age group appears to be children aged 1-17 years.
Prognosis is directly contingent on early recognition and appropriate intervention. Early diagnosis of boerhaave syndrome allows prompt surgical repair. Diagnosis and surgery within 24 hours carry a 75% survival rate. This drops to approximately 50% after a 24-hour delay and approximately 10% after 48 hours.
The mortality rate is high. Esophageal perforation is the most lethal perforation of the gi tract. Survival is contingent largely upon early recognition and appropriate surgical intervention.
Overall, the mortality rate is approximately 30%. Mortality is usually due to subsequent infection, including mediastinitis, pneumonitis, pericarditis, or empyema.
Patients who undergo surgical repair within 24 hours of injury have a 70-75% chance of survival. This falls to 35-50% if surgery is delayed longer than 24 hours and to approximately 10% if delayed longer than 48 hours.
Cases of patients surviving without surgery exist but are rare enough to warrant case reports in the medical literature.
Esophageal rupture may lead to the development of septicemia, pneumomediastinum, mediastinitis, massive pleural effusion, empyema, pneumomediastinum, or subcutaneous emphysema.
If the esophageal rupture extends directly into the pleura, hydropneumothorax is expected. In adults, this occurs more commonly on the left side of the pleura. In neonates, esophageal rupture usually occurs on the right side.
After esophageal rupture, free air enters the mediastinum and also may spread to the adjacent structures, resulting in mediastinal abscess or superimposed secondary infection.
Other complications include acute respiratory distress syndrome, pneumomediastinum, pneumothorax, and hydrothorax.
I done hysterectomy on 22-12-2014. Last 45 days , i have little/moderate vaginal bleeding . By usg it revealed vault hematoma of size 6.5 mm x 2.5mm size. Please advice. How long it will cure.
I am 32 yr. My period cycle was 4th March. I had unprotected sex in evening of 24 March. I have taken i-pill on 26 March in evening. Again I had unprotected sex on 28 March evening. Can I get pregnant in that case? If yes than how I can avoid that as my son is very small so wanted to avoid. Pl reply.
Ceaserian delivery ke baad kya unprotected sex kar sakte hai? Delivery ke baad menses nahi aye aur breastfeeding b continue hai toh kya hum bina protection ke sex karna chahiye?
For many people, popping a calcium tablet is something which has benefits, but at the same time does no harm. After all, who does not want to have strong bones and healthy teeth? The unfortunate part is that things are not so simple and a lot of research has debunked this.
Take, for example, the findings that when an old woman has calcium, the fracture rates are not all that different as compared to one who has not had calcium supplements. In addition to this, it was also found as part of a study that there is no positive impact on the mineral density of the hip.
As a matter of fact, calcium tablets and supplements can pose a significant risk, as well. While it is true that calcium does help in the effort of getting heart disease, an amount which is greater than the dietary limit does not. Actually, the excess calcium may increase the risk. This is true when it comes to calcium from supplements and not calcium which is absorbed by the way of food. So, what sort of additional risk is there? A study found that people who receive calcium from a tablet or another similar source have about a 140% greater chance of a heart attack!
How much is too much?
A thousand milligrammes of calcium in excess of the requirement on a daily basis is said to increase the risk of death from CVD or cardiovascular disease by about a fifth. Not a trivial amount, by any measure.
But why does this happen?
The key to answering this question comes from how the calcium is absorbed by the body. When calcium from food is eaten, the rate of it being released is a lot slower as compared to calcium from tablets. Also, when there is excess calcium, it is not absorbed and kept in reserve by the body but is excreted in the form of urine. So, this calcium going through the kidneys can cause some trouble there, as well!
Yes or No?
So, what is to be done in order to make sure one is having a sufficient amount of calcium? Well, there are a lot of sources and consuming things such as dairy products and fish, along with dark leafy vegetables are some great ways to get natural calcium. Only if a person has very low calcium levels should calcium tablets be consumed? It is well worth remembering that too much of a good thing is a bad thing! If you wish to discuss about any specific problem, you can consult a General Physician.