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Boerhaave syndrome as a complication of colonoscopy preparation: a case report
© Emmanouilidis et al; licensee BioMed Central Ltd. 2011
Received: 13 April 2011
Accepted: 5 November 2011
Published: 5 November 2011
Colonoscopy is one of the most frequently performed elective and invasive diagnostic interventions. For every colonoscopy, complete colon preparation is mandatory to provide the best possible endoluminal visibility; for example, the patient has to drink a great volume of a non-resorbable solution to flush out all feces. Despite the known possible nauseating side effects of colonoscopy preparation and despite the knowledge that excessive vomiting can cause rupture of the distal esophagus (Boerhaave syndrome), which is a rare but severe complication with high morbidity and mortality, it is not yet a standard procedure to provide a patient with an anti-emetic medication during a colon preparation process. This is the first report of Boerhaave syndrome induced by colonoscopy preparation, and this case strongly suggests that the prospect of being at risk of a severe complication connected with an elective colonoscopy justifies a non-invasive, inexpensive yet effective precaution such as an anti-emetic co-medication during the colonoscopy preparation process.
A 73-year-old Caucasian woman was scheduled to undergo elective colonoscopy. For the colonoscopy preparation at home she received commercially available bags containing soluble polyethylene glycol powder. No anti-emetic medication was prescribed. After drinking the prepared solution she had to vomit excessively and experienced a sudden and intense pain in her back. An immediate computed tomography (CT) scan revealed a rupture of the distal esophagus (Boerhaave syndrome). After initial conservative treatment by endoluminal sponge vacuum therapy, she was taken to the operating theatre and the longitudinal esophageal rupture was closed by direct suture and gastric fundoplication (Nissen procedure). She recovered completely and was discharged three weeks after the initial event.
To the best of our knowledge, this is the first report of a case of Boerhaave syndrome as a complication of excessive vomiting caused by colonoscopy preparation. The case suggests that patients who are prepared for a colonoscopy by drinking large volumes of fluid should routinely receive an anti-emetic medication during the preparation process, especially when they have a tendency to nausea and vomiting.
Spontaneous esophageal perforation, or Boerhaave syndrome, is a rare but severe complication caused by excessive vomiting. In Hermann Boerhaave's first report (1724) of a spontaneous esophageal rupture, he described the case of a man who deliberately and repeatedly induced vomiting after a rich meal . In contrast to Boerhaave syndrome, which involves a complete rupture of the esophagus, Mallory-Weiss syndrome  is characterized by fissure-like lesions of the mucosa, which are characteristically arranged around the circumference of the cardiac opening along the longitudinal axis of the esophagus. Mallory-Weiss lesions extend up into the esophagus or down into the cardiac opening of the stomach and can be perceived as an incomplete Boerhaave syndrome . While Boerhaave syndrome presents with extensive retrosternal and paravertebral back pain, patients with Mallory-Weiss are usually brought to medical attention by violent retching followed by hematemesis .
The typical location of a Boerhaave perforation is the left distal esophagus just above the distal esophageal sphincter. Korn et al.  described a match of the typical location of the Boerhaave rupture with the contact zone of 'clasp' and oblique muscle fibers at the distal esophageal sphincter. This location is often associated with the coexistence of a hiatus hernia and/or a localized loss of elasticity of the esophagus wall due to chronic esophageal alterations such as scarring transformations induced, for example, by gastric reflux, Barrett's lesions or small injuries after repeated episodes of vomiting [1, 6–9]. In most reported cases, vomiting was induced by excessive alcohol misuse [8–11] or other forms of intoxication . Very few other causes have been described; they include Boerhaave syndrome caused by gastroscopy . To the best of our knowledge, this is the first report of a case of Boerhaave syndrome as a consequence of colonoscopy preparation.
A 73-year-old Caucasian woman was scheduled to undergo elective colonoscopy. She had no history of gastric reflux or any other record of an upper gastrointestinal chronic or acute disease. Her known medical history consisted of mild hypertension, a prosthetic hip joint, and colon diverticulosis.
Due to its rare incidence, most Boerhaave reports in the medical literature are case reports, (for example, [14–20]), and rarely a larger series of patients with Boerhaave from a single center . For Boerhaave syndrome, excessive vomiting is an absolute prerequisite, and this was also true in our patient's case. But, while excessive vomiting in almost all other cases was spontaneous and, except for one reported case , was independent of any elective iatrogenic intervention, in our patient's case vomiting was triggered by a routine and very common procedure of colonoscopy preparation.
Diagnostic investigations and treatment of our patient were not spectacular; however, as our patient presented with the typical signs of persistent and slightly increasing back pain, which started immediately after vomiting, diagnostic investigations by esophagogastroscopy and CT scan with oral CM easily revealed a Boerhaave perforation at the esophagogastric junction.
The initial idea to use vacuum endo-sponge therapy to treat the perforation arose because we have been using this kind of interventional therapy successfully for the treatment of anastomotic insufficiencies in upper gastrointestinal surgery [21, 22]. However in this case, and perhaps due to the small size of the perforation, the vacuum seemed to have no draining effect on the gradually forming mediastinal abscess, and consequently the condition of our patient slowly deteriorated. For this reason, we decided to stop the endo-sponge VAC therapy and treat her by open surgery with direct suture and covering by Nissen fundoplication.
Our patient later recalled that she had a history of becoming nauseous easily, but this information was never documented, and nor did she pass on this information at the time of the colonoscopy clarification interview. It is also likely that possible nauseous conditions were not addressed by the interview at all. However, since an anti-emetic medication might have prevented this unfortunate event, it is important to pay attention to possible nauseous conditions before a planned colonoscopy preparation.
In view of the risk of a severe complication connected with an elective colonoscopy, we conclude that it is justified to prescribe an anti-emetic co-medication as a non-invasive, inexpensive yet effective precaution against excessive vomiting for any routine colonoscopy preparation.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors acknowledge Jochen Wedemeyer, Johannes Hadem, Niels C Hellige and Camilla Regler.
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