BOERHAAVE'S SYNDROME

Asuka Suzuki Sodexo Healthcare Services Southcoast Hospitals Group, Dietetic Intern June 7, 2013

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What is Boerhaave's syndrome?

straining vomiting

Sudden Increase in Intraesophageal Pressure

Negative Intrathoracic Pressure

Spontaneous perforation of the esophagus

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Admission
46 years old gentleman No weight change before admission
Past Medical History Poly-substance abuse cocaine abuse Bipolar disorder Hepatitis C PTSD (posttraumatic stress disorder) Home Medication Lithium: Management of bipolar disorders Ativan: Management of anxiety disorders

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4/14/13 Before Admission

He has had episodes of sounds like upper respiratory tract type infection with some nausea and strenuous vomiting. During the vomiting, he experienced acute onset of sharp epigastric pain which radiated through to his back.

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CT Scan
IMPRESSION:
1. 2.

No pulmonary emboli. Pneumomediastinum. Fluid and air around the distal esophagus.
Barium Swallowing
.

Positive distal esophageal perforation

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Operation
Distal esophageal perforation secondary to Boerhaave syndrome

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Date

Weight (kg)

Balance (ml)

In (ml) IV fluid +med 3915

LR

PEJ

Out (ml) Urine

NG, Chest, JP-tube

Alb

Na

4/14 4/15

74.6 75.9

+1795 -507.5

100? 2830

2020 1167

4.9 -

140 135

3489.5
LR

4/17

74.8

-1067

3595
D5 1/2NS

4/16 PEJ Placed

3195

1465

2.6

137

4/18

-2095

3145
D5 1/2NS

60 flush

4560

740

134

4/19

-92

3808
D5 1/2NS

220 Vital1.2

3275

845

136

4/21

70.9

+779

1230
D5 1/2NS

1900ml Vital1.2

2275

76

135

4/23

72.7

+447

915
D5 1/2NS

2080 Vital1.2 Off/p.o p.o

2525

23

3.0

135

4/26 4/27

72.5 -

-2483 -3015

Off 240
NS

5400? 4640?

90 0

131 136

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Nutrition Intervention 4/14 - 4/19/13

4/16 Jejunostomy (PEJ) placed Dr. was waiting for feeding due to A-fib. 4/19 Start feeding through PEJ
Ht 62 BMI 21.1 Calculated with initial weight 75kg/165# Kcal: 1875kcal -2250kcal (25-30kcal/kg) Protein: 84g-113g (1.2-1.5g/kg) Fluid: 2625ml (35ml/kg)

Vital 1.2 @ 20ml (goal 70ml/hr) advanced per MD 2016kcal, 126g protein, water 1362ml + flush 200ml every 4 hours without iv fluid

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Nutrition Intervention 4/20 4/23/13

4/20 Pt tolerated vital 1.2 at goal rate 70ml/hr 4/23: Barium swallow No evidence of esophageal leak.

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Nutrition Intervention 4/24/13

12/24 Resume diet: Full liquid Fair intake. Pt stated good appetite, but just does not like some of the foods. Continue vital 1.2 via PEJ at 70ml/hr. Start calorie count for 7 days for ability to wean tube feeding.

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Nutrition Intervention 4/26 4/30/13

Diet: Surgical Soft Fair po intake. Well tolerated D/C tube feeding PEJ flushes for patency Ensure complete TID (1050kcal, 39g protein) Educated pt on low residue diet 4/30 Pt discharged to group home.

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Re-Admission 5/6/13

Patient was doing well after discharge in 4/30 After a few days, he felt tenderness surrounding the PEJ Pain in the abdominal area and radiating to his back Patient had nausea and multiple emesis Bright red blood per rectum (no melena before this episode) H/H, Vital were stable

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CT Scan: Abd/Pelvic & Upper Endoscopy

CT Scan: Abd/Pelvic
PEJ

in good place Possibly gastritis

Upper Endoscopy (esophagus, stomach, duodenum)

Possibly bleeding is from the upper GI tract and not from the jejunum or lower

No

definitive site of bleeding NPO

5/6:

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Nutrition Intervention 5/7/13

5/7/13 155# (4/26/13 160# -- 5# wt loss within 2 weeks)

Poor intake after d/c pt did not like food in group home

BMI 21.0 Nutritional Needs

Calorie: 1760 kcal 2115 kcal (25-30 kcal/kg) Protein: 92g (1.3g/kg) Fluid: 2465 (35ml/kg)

5/7 Resume diet: Clear Liquid Ensure clear provided until diet is advanced Pt stated he is hungry

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Nutrition Intervention 5/10 5/11/13

5/10: Advanced to regular diet as tolerated After discussed at round, downgrade to surgical soft/ low residue diet for safety Changed from ensure clear to coffee ensure BID Pt is fair po intake. Tolerated meals.

5/11 Pt discharged to group home.

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Re-Admission: 5/14/13

After discharged (5/11) patient had small amount of blood each time he has a bowel movement which was getting severe 5/12-5/13, he had a pain around PEJ, but no nausea and vomiting 5/13: he had lots of bright red blood when he had a bowel movement 5/15: Upper endoscopy
No

stigmata of recent bleeding No active bleeding

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Nutrition Intervention 5/15/13

5/15/13 Pt has been eating less at group home

Fear of re-opening esophagus tear Dislikes foods and supplements at group home Alb 2.8

Wt 155#/ 70.5kg (same as previous admission) BMI 21.0 Nutritional Needs

Calorie:

2115-2460 kcal (30-35 kcal/kg) Protein: 85-106g (1.2-1.5 g/kg) Fluid: 2460 (35ml/kg)
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Nutrition Intervention 5/16/13

5/14 Resume diet: Clear liquid

MD consult for cyclic tube feeding

5/16 Advanced to regular as tolerated

Recommend soft diet with ensure complete TID (1050kcal, 39g protein) Cyclic TF started this evening

Vital 1.2 @ 80ml/hr from 6:00 pm - 6:00 am 1152kcal, 71g protein with minimal free water flushes to maintain tube patency (~90ml before and after)

Do not recommend bolus TF due to PEJ unable to tolerate

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Nutrition Intervention 5/16 5/17/13

5/16: Discussed with RN and Case Manager

Pt

was from group home, but they cannot manage cyclic tube feeding Pt will discharge soon, so no adequate time for pt to learn how to manage tube feeding Case manager putting in referral for a nursing home

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Discharge 5/17/13

Nocturnal tube feeding well tolerated Regular diet: fair intake Discussed with patient, MD, RN, case manager and person from southeast mass health & rehab

Patient d/c to rehab to provide adequate time for him to learn TF

5/17: Discharged

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