What Causes Boerhaave’s Syndrome?

Boerhaave’s syndrome, or a spontaneous esophageal rupture, is a condition where the esophagus incurs a tear that penetrates all the way through it. An esophageal rupture is extremely problematic because it allows stomach acid, air, and food to leak out of the esophagus and into the chest. This causes severe inflammation and fluid accumulation around the lungs. Symptoms of Boerhaave’s syndrome include abdominal pain, low blood pressure, fever, chest pain, vomiting, and vomiting blood. Boerhaave’s syndrome can be diagnosed using an esophagography and x-rays of the individual’s abdomen and chest. The only treatment for Boerhaave’s syndrome is the surgical repair of the tear in the patient’s esophagus. Prior to the surgical procedure, the affected individual is given broad-spectrum antibiotics to reduce the chance of infection. There are numerous mechanisms that can cause Boerhaave’s syndrome.

Forceful And Excessive Vomiting

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Boerhaave’s syndrome caused by forceful and excessive vomiting is a rare occurrence. Typically, this type of vomiting typically occurs after an individual drinks excessive amounts of alcohol or eats an excessive amount of food. In some cases, violent vomiting can be caused by certain medical treatments and medications like chemotherapy. Widespread infections and consumption of illegal drugs can also result in excessive vomiting. Any one of these factors can induce severe and intense vomiting that causes the intraluminal esophageal pressure or the pressure inside of the individual’s esophagus to rapidly and suddenly rise. The cricopharyngeus muscle fails to relax, and the excessive pressure usually causes a tear in the left lower section of the individual’s esophagus. Another common region where an esophageal tear can occur due to forceful and excessive vomiting is in the bottom of the esophagus underneath the point where the individual’s diaphragm is located. Should the tear happen above the diaphragm, respiratory symptoms and chest pain will result. If the tear occurs below the diaphragm, the individual will experience symptoms in the abdominal region including pain and a burning sensation.

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Epileptic Seizures

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An epileptic seizure can cause an individual to incur a tear in their esophagus. A seizure happens when the patient’s brain has an abnormal electrical discharge. Similar to a short circuit, the patient will experience a behavioral change without being aware of it. Some seizures do not cause erratic movements, but others can cause violent and jerking movements. Epilepsy is a disorder characterized by frequent seizure activity in an individual. Because this electrical discharge in the brain of a patient having a seizure causes erratic muscular dysfunction, the muscle coordination of the esophagus and surrounding muscles will be lost. In a healthy individual who is not having a seizure, certain muscles in the esophagus help ensure its interior pressure does increase to a dangerous level. However, in an individual who is epileptic and experiencing a violent seizure, this mechanism to prevent excessive pressure build up in the esophagus will not be functional. Consequently, a mild injury to the esophagus can occur or the esophagus can tear all the way through during a seizure, causing Boerhaave’s syndrome.

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Trauma To the Abdomen

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In rare cases, Boerhaave’s syndrome may be caused by certain types of trauma to the abdomen. A case of Boerhaave’s syndrome was reported where an individual experienced an esophageal rupture due to the impact on the body from a high elevation fall. Another example of trauma-induced Boerhaave’s syndrome is where a heavy object fell on top of an individual’s chest and abdominal cavity. In addition, cases of Boerhaave’s syndrome have occurred where an individual was hit with an automobile as a pedestrian. Another common cause of trauma that results in Boerhaave’s syndrome are injuries sustained from an explosion or blast. A gunshot wound or sharp object penetration of the upper abdominal area of an individual can cause the esophagus to perforate completely. The exact mechanism of how non-penetrative abdominal trauma causes the patient’s esophagus to rupture remains unclear, but it is thought the esophagogastric sphincter remaining closed during impact is a key factor. When this sphincter remains closed, an influx of pressurized air to pushes on the cricopharyngeal sphincter and causes the esophagus to perforate.

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Weight Lifting

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Some individuals may experience a tear of the esophagus as a result of heavy weight lifting activity. This can be from lifting heavy objects such as furniture during a move, or it could be attributed to the sport of weight lifting. Weight lifting as a sport involves the activity of an individual lifting weighted barbells in a single-movement lift from the floor to shoulder position. Sometimes the barbells are lifted from the shoulder position to the extended position above an individual’s head. Should an internal mechanism cause the individual’s esophagogastric sphincter to stay in a closed position during the weight lifting exercise, it is possible for the individual to experience tearing in their esophagus. The exercise of weight lifting or lifting of a heavy object can cause the abdominal muscles to contract and push air upwards towards the esophagus. When an influx of pressurized air is pushed into the esophagus, and the esophagogastric sphincter does not open to allow its release, the esophagus will dilate. If this dilation reaches a certain threshold, the patient’s esophagus will perforate under pressure.

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Severe Constipation

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Severe constipation is a form of bodily strain that can result in Boerhaave’s syndrome. Constipation occurs when an internal mechanism or malfunction occurs in an individuals digestion process. In healthy individuals, food moves from their stomach to their small intestine where nutrients are absorbed, and then it moves into the large intestine where the remaining fluid is absorbed before defecation. Constipation occurs when the food remains in an individual’s large intestine for too long, and the intestine absorbs too much fluid from it. This over absorption of fluid causes the stools to become very hard and difficult to pass out of the body. Patients who have chronic constipation tend to exhibit intense straining of the abdominal muscles in an effort to remove the stool from their body. This mechanism causes the same type of internal pressure on the esophagus as lifting a heavy object does. Should an individual’s esophagogastric sphincter stay in a closed position during this straining, the esophagus can dilate and rupture, causing Boerhaave’s syndrome.