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Brain abscess is a life-threatening infection that can occur secondary to contiguous or hematogenous spread. Several underlying conditions can lead to brain abscesses, such as dental infection, otitis media, sinusitis, and immunosuppression. Esophageal perforation leading to brain abscesses is extremely rare. We report a rare case of a 32-year-old man who presented to the emergency department with progressive headaches and upper-extremity weakness. Upon further evaluation, computed tomography (CT) revealed multiple brain abscesses secondary to Streptococcus intermedius infection. The patient eventually underwent esophagogastroduodenoscopy (EGD), which showed a perforation in the middle third of the esophagus. This case highlights the importance of considering esophageal perforation as a predisposing condition for brain abscesses., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

What is the optimal management of spontaneous pneumomediastinum (SPM) and is there a risk of esophageal perforation in patients with SPM? We performed a retrospective case-control study of children through age 21, diagnosed with SPM in one hospital system over 10 years with the primary aim of describing the diagnostic workup, treatment patterns, and clinical outcomes. We hypothesized that SPM is a self-limited disease and is not associated with esophageal injury. Cases were identified using International Classification of Disease codes and excluded for trauma or severe infections. Median age was 16 years, 66% were male ( n = 179). Chest radiography was performed in 97%, chest computed tomography (CT) in 33%, and esophagrams in 26%. Follow-up imaging showed resolution in 83% (mean = 17.2 days). SPM was not associated with esophageal perforation. We recommend avoiding CT scans and esophagrams unless there is discrete esophageal concern. Management of SPM should be guided by symptomatology., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Pneumomediastinum is a potentially life-threatening condition. Patients can present with a variety of symptoms at the emergency department. Pneumomediastinum can be spontaneous or secondary due to perforation of the esophagus or tracheobronchial tree., Case Description: A 20-year old man was seen at the emergency department with the suspicion of esophageal perforation. He noticed subcutaneous 'crackles' arising after an episode of severe vomiting. In the emergency room a non-acute ill patient was seen with subcutaneous emphysema of the neck and chest. A CT-scan with oral contrast did not show esophageal contrast leakage or other pathology that could be the cause of his pneumomediastinum. Therefore, we diagnosed the patient with a spontaneous pneumomediastinum. He was discharged after an observation period of 24 hours., Conclusion: Spontaneous pneumomediastinum is a rare, self-limiting disease with an excellent prognosis. Differentiating spontaneous pneumomediastinum from more severe secondary causes will avoid unnecessary therapy and prolonged hospitalization.

Background: Spontaneous pneumomediastinum (SPM) is a rare and often unrecognized condition of which vomiting is one of the reported triggering factors. Differentiating SPM from Boerhaave's syndrome (pneumomediastinum secondary to esophageal breach) is the first step in management and prognosis., Observation: A 27-year-old woman with systemic lupus erythematous presented to the emergency department with epigastralgia, incoercible vomiting and diarrhoea. Abdominal CT showed circumferential thickening of the duodenum and bilateral ureteritis. Chest sections showed pneumomediastinum extending to the cervical region. Therapeutic management was based on prophylactic antibiotic therapy and an absolute diet (fasting). A CT scan with upper gastrointestinal opacification was performed to prevent esophageal rupture and showed quasi-obstructive thickening of the antral mucosa. The diagnosis was lupus enteritis and pneumomediastinum was secondary to the vomiting efforts. The patient was placed on corticosteroids and a favorable outcome ensued., Conclusion: Strenuous vomiting is one of the precipitating factors of SPM. Boerhaave's syndrome is the main differential diagnosis with a poor prognosis, unlike SPM, which has a good prognosis with conservative treatment., (Copyright © 2022 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

We herein report a 61-year-old man who sustained injury after a 2-m fall and developed mediastinitis. He presented to another hospital two days after the fall and was transferred to our hospital four days after the fall with a fever and dysphagia. Computed tomography revealed osteophytes on the second and third thoracic vertebrae and free air in the mediastinum, indicating esophageal perforation. Emergent surgery was performed. Intraoperatively, a longitudinal esophageal tear was identified. We stress the importance of being aware of the possibility of osteophyte-related esophageal perforation in patients with a history of a fall. A delayed diagnosis affects the prognosis.

Esophageal injuries in the setting of trauma are rare, with an incidence of .001 % in the setting of blunt chest trauma. The duration of time from injury to repair is the main factor that influences the high mortality and morbidity rates of esophageal injury secondary to blunt trauma. This paper presents a case of esophageal injury secondary to blunt trauma resulting from a 25 foot fall. The patient presented three hours after the injury with esophageal perforation noted on CT scan. The patient then underwent prompt surgical repair. It is of paramount importance for investigators to maintain a high index of suspicion for esophageal perforation in poly-trauma patients presenting with blunt chest injury as a missed diagnosis can lead to worse outcomes and limited repair options for patients.

Rationale: Surgical treatment remains the most effective option for treating Boerhaave's syndrome. However, in cases of postoperative anastomotic leakage of Boerhaave's syndrome, endoscopic interventions such as over-the-scope clip, stenting, or cyanoacrylate injection have emerged over reoperation., Patient Concerns: We report the case of a 50-year-old male patient who presented with vomiting and abdominal pain after alcohol consumption. Laparoscopic surgery was performed for primary closure of a laceration at the lower esophagus, and for the closure of a Boerhaave's syndrome, which was detected by abdominal computed tomography. However, postoperative anastomotic leakage was confirmed through esophagography after the operation. In our case, endoscopic treatment with an over-the-scope clip and stenting were not effective for the repair of the anastomotic leakage, but cyanoacrylate injection successfully healed the anastomotic leakage., Diagnoses: Boerhaave's syndrome was initially detected by abdominal computed tomography, but postoperative anastomotic leakage after the operation was confirmed with esophagography., Interventions: A total of 2.0 cc of N-butyl-2-cyanoacrylate and lipiodol mixture (at 1:1) was injected into the leakage tract through the perforation entrance., Outcomes: Complete healing of the anastomotic leakage was confirmed with a follow-up esophagoscopy., Lessons: N-butyl-2-cyanocrylate injection treatment can be used as a rescue option for postoperative leakage when over-the-scope clips and stenting fail for this indication., Competing Interests: The authors disclose no relevant financial support or conflicts of interest. The authors have no potential conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Competing interests: None declared.

Purpose: Pneumomediastinum is not an uncommon finding on emergency CTs and is seen in a variety of settings, including acute trauma, recent repeated emesis and recent thoracic surgery, and after EGD (Kouritas et al. J Thorac Dis 7(Suppl 1):S44-S49, 2015). The purpose of this study was to examine cases of CT pneumomediastinum for distinguishing features which could support or exclude esophageal injury as a cause, which in turn could help guide evaluation of these patients., Methods: CT chest scans showing pneumomediastinum performed in the emergency department between January 2013 and December 2018 were included. The presence or absence of fluid within the mediastinal compartments was correlated with esophageal perforation and subdivided into the clinical scenarios of trauma, suspected Boerhaave's syndrome, recent surgery or EGD, and other. Accuracy of this finding was compared with fluoroscopic esophagography., Results: Twenty-two cases of esophageal perforation were identified out of a total of 324 included cases. The cases were subdivided into four categories: trauma, suspected Boerhaave syndrome, suspected iatrogenic perforation from recent procedure or surgery, and other. Two hundred fourteen cases of pneumomediastinum occurred in the setting of trauma, and 2 had esophageal perforation. Both showed mediastinal fluid. Twenty-two cases had mediastinal fluid without perforation. Seventeen cases of pneumomediastinum occurred in the setting of suspected Boerhaaves, and 3 had esophageal perforation. Every case with esophageal perforation had mediastinal fluid, and every case without perforation had no mediastinal fluid. Nine cases of pneumomediastinum occurred in the setting of suspected iatrogenic perforation after recent surgery or procedure. Six cases had esophageal perforation, and 5 of these had mediastinal fluid. All three cases without perforation also had mediastinal fluid. Eighty-six cases were classified as other and included a variety of clinical histories. This category contained 8 esophageal perforations, 7 of which had mediastinal fluid. One case of mediastinal fluid was not associated with esophageal perforation in this category., Conclusion: The presence of mediastinal fluid, specifically within the visceral compartment, strongly suggests esophageal injury, and its absence strongly argues against it. An important caveat is in the setting of recent surgery, in which mediastinal fluid can be seen normally. An esophagography study can supplement the evaluation if there is a discrepancy between the clinical suspicion and the original CT findings.

Spontaneous oesophagus rupture, also known as Boerhaave syndrome, is a rare but near-fatal medical condition and despite recent medical advancements, it remains a diagnostic challenge for front-door clinicians. The authors describe a similar presentation in an elderly gentleman who presented to the emergency department with sudden chest pain post vomiting. His initial chest radiograph showed bilateral dense consolidations and pleural effusions, and was treated as sepsis secondary to bilateral pneumonia. He underwent computed tomography pulmonary angiogram to rule out pulmonary embolism because of his chest pain with elevated D-dimer which confirmed the diagnosis of oesophagus rupture. His care was transferred to Surgical and Intensive care colleagues with plans for radiological chest drain insertion to limit contamination of mediastinum, however the patient became hypoxic and hypotensive and despite maximal organ support passed away within 6 hours of admission. Retrospect review of chest radiograph revealed Peri-oesophageal air tracking, a sign of Boerhaave syndrome. The aim of this case is to emphasise the importance of raising the suspicion of Boerhaave syndrome in patients with sudden chest pain, unexplained pleural effusion or pneumothorax with a history of recent vomiting as early diagnosis holds the key to prompt lifesaving management.

An 83-year-old female patient presented to the Emergency Department with shortness of breath, difficulty swallowing and left-sided chest pain following a vomiting attempt. A rupture in the left lower third of the esophagus, with hydropneumothorax, pneumomediastinum, and subcutaneous emphysema was revealed by chest X-ray, thoracic computed tomography scan, and contrast esophagography. The patient was successfully treated conservatively with closed thoracostomy, intravenous fluids, parenteral nutrition, and broad-spectrum antibiotics coverage. Following the successful conservative treatment, the patient developed a distal esophageal stenosis which was treated with an intra-esophageal self-expanding stent., (Copyright: © 2021 Permanyer.)

Background: Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis., Aim: Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported., Methods: Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper., Results-Systematic-Literature-Review: Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space., Results-Illustrative-Case-Report: Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days., Study Limitations: Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population., Conclusions: Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.

Objectives: Ingestion of a foreign body can cause different degrees of damage to esophagus, and several complications are potentially life-threatening if not properly handled. The aortic injury caused by a perforating esophageal foreign body is rare but lethal. The optimal management still remains controversial. The purpose of this report is to describe our experience in the management of the aortic injury caused by esophageal foreign body ingestion., Methods: Between January 2015 and December 2015, we retrospectively enrolled cases of esophageal perforation involving the aorta by foreign body. The general parameters, esophageal foreign body, types of aortic injury, treatment, and outcome were analyzed. Additionally, we reviewed the literature of the management of esophageal perforation involving the aorta caused by foreign bodies. The study was approved by the ethics committee of the First Affiliated Hospital, College of Medicine, Zhejiang University, and the need for informed consent was waived (Quick review 2019, No. 609)., Results: Three cases of esophageal perforation involving the aorta by foreign body was selected in the study. Two male and 1 female patients (range, 51-58 years old) with the aorta involvement caused by a perforating foreign body in the esophagus in 3 forms were identified, including 1 patient with mycotic aortic pseudoaneurysm, 1 patient with aortoesophageal fistula and 1 patient with the aortic intramural hematoma. One patient died of the rupture of the pseudoaneurysm during the preparation of the surgery. The other 2 patients were cured with a multidisciplinary approach, which is an urgent thoracic endovascular aortic repair followed by mediastinal debridement/drainage or endoscopic retrieval. Two of 3 patients were survived until now., Conclusion: The management of the aortic injury caused by esophageal foreign body injury is challenging. Early diagnosis and multidisciplinary management is crucial.

A 67-year-old male presents with complaints of severe retrosternal pain, frequent vomiting and dysphagia. Endoscopy revealed a very large intramural oesophageal hematoma, obliterating the lumen. Additional CT-imaging showed peri-oesophageal air collections, indicative for oesophageal perforation (compatible with Boerhaave's syndrome). Patient was treated successfully with intravenous antibiotics and fluid. Follow-up endoscopy after one year showed full recovery of the oesophageal wall.

A 14-year-old male was admitted to the Emergency Department with sore throat and cough. One hour after his admission, he presented a hemodynamic compromise with a respiratory failure. The thoracic tomodensitometry highlighted a tension bilateral pneumothorax and mediastinum consecutive to an esophageal rupture in the left posterolateral wall also known as Boerhaave's syndrome which was treated successfully with a non-operative management. To avoid a recurrence of bilateral pneumothorax, a left pleuroscopy with talc pleurodesis was performed., (© Acta Gastro-Enterologica Belgica.)

Rationale: Acute chest pain remains one of the most challenging complaints of patients presenting to emergency departments (EDs). The diverse etiologies of chest pain frequently lead to diagnostic and therapeutic challenges. Esophageal perforation is a rare but potentially life-threatening disease. It results in delayed diagnosis and an estimated mortality risk of 20% to 40%. Prompt diagnosis and immediate therapeutic interventions are key factors for a good prognosis., Patient Concerns: Case 1 involved a 66-year-old man who presented to the ED with acute chest pain radiating to the back and hematemesis. Emergent contrast thoracic computerized tomography (CT) indicated the presence of a massive pneumothorax with pleural effusion. The continuous drainage of a dark-red bloody fluid following emergent thoracic intubation led to the discovery that the patient had experienced severe vomiting after whiskey consumption before admission to the hospital. Re-evaluation of the CT indicated spontaneous pneumomediastinum, whereas barium esophagography confirmed the presence of an esophageal perforation. Case 2 involved an 18-year-old Vietnamese man admitted to our ED with acute chest pain and swelling of the neck after vomiting due to beer consumption. A chest x-ray indicated diffuse subcutaneous emphysema of the neck and upper thorax. Contrast CT indicated pneumomediastinum with extensive emphysema and air in the paraspinal region and spinal canal., Diagnoses: Both of the 2 cases were diagnosed as spontaneous perforation of the esophagus (Boerhaave syndrome [BS])., Interventions: Case 1 received surgical interventions, whereas case 2 decided not to avail our medical services., Outcomes: Case 1 was discharged after a good recovery. Case 2 lost to follow-up., Lessons: We recommend all physicians in the ED to raise their index of suspicion for BS when dealing with patients having acute chest pain, dyspnea, confirmed pneumothorax, or newly-developed pleural effusion.

Background: There is a lack of experience with fully covered self-expandable metal stents (SEMSs) for the treatment of esophageal leakage particularly in infants and neonates., Methods: Eight patients (5M, 3F) with a median age of 17 months (range, 1-135 months) who underwent treatment with SEMSs for an anastomotic leakage or perforation of the esophagus were recruited to this retrospective study. Four children were born premature. In six patients the stents were placed primarily as an emergency procedure., Results: Median duration of individual stent placement was 42 days (range, 13-72 days). Six out of eight patients (75%) were treated with one stent only. In three preterm infants who had their stents inserted within the first month relative weight gain was 17% compared with 2% in five patients who were treated later in life (p=0.0986). In four cases (50%) distal migration of the stent was observed. Seven out of eight patients (88%) had their leakage resolved after stent therapy., Conclusions: Insertion of fully covered SEMSs is an alternative tool for the treatment of esophageal leakage in children and preterm infants, and successful with only one single application in selected cases. It can be used either following previous therapy or as part of an emergency procedure. Because of the absence of manufactured, age-related devices SEMSs that are originally designed for other organs can be applied., Competing Interests: Authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Esophageal perforations are associated with high morbidity and mortality. Different nonoperative and operative treatment options have been proposed. This study focuses on the impact of different surgical treatments in nonmalignant esophageal perforations and tries to identify predictors of mortality in a single tertiary center over a 15-year period., Methods: From 2002 to 2017, patients with surgically managed esophageal perforation were identified from our database. Patients with esophageal malignancies were excluded. Etiology, clinical data, treatment, and outcome were analyzed. A multivariate logistic regression analysis was performed to investigate the impact on mortality., Results: A total of 72 patients were identified. The majority of perforations were iatrogenic (54.2%) followed by Boerhaave's syndrome (23.6%). Most ruptures were found in the distal third of the esophagus (59.7%) measuring <3 cm (61.1%). Patients were treated with exploration and drainage (8.3%), primary suture and patch reinforcement (36.1%), resection and restoration of continuity (25.0%), or resection without restoration of continuity (30.6%). Delayed therapy significantly correlated with sepsis (p < 0.0001) and mortality (p = 0.032). A correlation between an increasing perforation length with sepsis (p = 0.012) was observed. A higher Perforation Severity Score (PSS; OR 4.430; 95% CI 1.143-17.174; p = 0.031) and a higher American Society of Anesthesiologists (ASA) score (OR 2.923; 95% CI 1.011-8.448; p = 0.048) were associated with mortality in multivariate analysis., Conclusion: Esophageal perforations are associated with high mortality, and larger ruptures are associated with worse outcome. Rapid diagnosis and treatment are crucial for patient survival. Hence, PSS and ASA score help to identify high-risk patients. The advantage of surgical management lies in the rapid control of the septic focus in an already critically ill patient. Though, the kind of surgical technique needs to be adjusted to the individual situation., (© 2019 S. Karger AG, Basel.)

A runner competing in a 100 mile trail race presented with severe lower chest pain and right upper abdominal pain. His pain started immediately after he took an over the counter non steroidal anti-inflammatory pill a few hundred metres after leaving the aid station. When he took the pill, he immediately had to vomit and spit out the pill. On arriving back at the aid station, he was noted to have severe left-sided chest pain that worsened with reclining. He also had profound dyspnoea. Initial vital signs were unremarkable. The runner was immediately transported to an emergency room and eventually found to have an oesophageal rupture. After surgical intervention and a lengthy recovery, the runner is back to participating in sport., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A 68-year-old woman presented with haematemesis and chest pain 3 months after a spontaneous oesophageal perforation. The patient rapidly progressed to a state of hypovolaemic shock and after resuscitation was found to have aorto-oesophageal fistula on CT aortogram. The patient was treated with a successful thoracic endovascular aortic repair., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Esophageal perforation has a high mortality rate. Fluoroscopic esophagography (FE) is the procedure of choice for diagnosing esophageal perforation. However, FE can be difficult to perform in seriously ill patients., Methods: We retrospectively reviewed charts and scans of all patients who had undergone thoracic CT (TCT) without oral contrast and FE for suspicion of esophageal perforation at our hospital between October, 2010 and December, 2015. Scans were interpreted by a single consultant radiologist having > 5 years of relevant experience. Statistical analysis was performed using SPSS version 20. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TCT were computed using FE as reference standard., Results: Of 122 subjects, 106 (83%) were male and their median age was 42 [inter-quartile range (IQR) 29-53] years. Esophageal perforation was evident on FE in 15 (8%) cases. Sensitivity, specificity, PPV and NPV of TCT for detecting esophageal perforation were 100, 54.6, 23.4 and 100%, respectively. When TCT was negative (n = 107), an alternative diagnosis was evident in 65 cases., Conclusion: Thoracic computed tomography (TCT) had 100% sensitivity and negative predictive value for excluding esophageal perforation. FE may be omitted in patients who have no evidence of mediastinal collection, pneumomediastinum or esophageal wall defect on TCT. However, in the presence of any of these features, FE is still necessary to confirm or exclude the presence of an esophageal perforation.

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

Boerhaave syndrome is a transmural disruption of the esophagus, due to an increase in esophageal pressure and is associated with high morbidity and mortality. There are cases reported secondary to bowel obstructions such as incarcerated hernias and gallstone ileus. Here, we describe an unusual autopsy case of Boerhaave syndrome, due to bowel obstruction secondary to biliary adenocarcinoma, which has never been reported in the literature. The patient was an 87-year old male presenting with severe chest and epigastric pain. Computed tomography showed fluid-filled esophagus, gastric distention and an ill-defined mass within the liver. Patient underwent esophagogastroduodenoscopy, which revealed esophageal rupture. Patient expired within 20 hours of admission. On autopsy, the decedent was found to have an esophageal perforation and an inferior hepatic mass, which morphologically and immunohistochemically was consistent with a biliary adenocarcinoma., (© 2019 by the Association of Clinical Scientists, Inc.)

We herein report a case of late diagnosed thoracic esophageal perforation. A 60-year-old man was diagnosed as an esophageal perforation with mediastinitis and pericardial abscess by detailed history taking, chest computed tomography, esophagoscopy and inflammatory findings in his blood test. Surgical drainage of mediastinum and pericardium was able to effectively control infectious process and pericardial fibrosis. Endoscopic esophageal stent placement on the thoracic- esophageal fistula promoted healing of the esophageal wall defect and enabled him to restart oral intake. This case report suggests that detailed history taking is important for all patients. Effective drainage of mediastinum and the use of esophageal stent may be the treatment options for late-diagnosed esophageal perforation.

Esophageal perforation (EP) can be a complication of radiofrequency ablation, a standard treatment for certain patients with drug-refractory atrial fibrillation. This article discusses the etiology, clinical manifestations, and diagnosis of EP, as well as nursing care for patients with EP.

Objective and Importance Boerhaave's syndrome is a sudden and rare form of oesophageal rupture and is often complicated by local or systemic infection of the mediastinum or pleural cavity. Several micro-organisms are documented as cause of pleural empyema in patients with Boerhaave's syndrome. Intervention (& Technique) We report on a previously healthy 74-year-old male who was admitted at a regional hospital with severe retrosternal and abdominal pain after an episode of vigorous vomiting the morning after ingestion of large quantity of beer. A CT-scan confirmed the diagnosis of Boerhaave's syndrome, an oesophageal stent was placed and a left-sided pleural empyema necessitated chest tube drainage. Pleural fluid samples were cultured every two days and were positive for Proteus mirabilis on day 2 after admission and for Saccharomyces cerevisiae on day 8 after admission. Intravenous fluconazole 800 mg per day was added to the antibacterial treatment. Pleural fluid culture became negative for P. mirabilis on day 23 and for S. cerevisiae on day 13. Recurrent empyema necessitated intrapleural thrombolysis. The patient could be discharged from the ICU after 43 days, from the normal ward to a rehabilitation centre after an additional 13 days. Conclusion Pleural empyema caused by S. cerevisiae, commonly known as 'Brewers' yeast', has never been described in such patients. Our case illustrates that clinicians should be aware of infection with S. cerevisiae after oesophageal perforation, soon after ingestion of beer. Adequate antimycotic treatment was successful and led to negative culture of pleural fluid after 5 days.

Although death from food is not an uncommon finding in forensic facilities worldwide, the range of underlying lethal mechanisms and associated conditions that should be sought at the time of autopsy is quite disparate. Deaths may occur from i) infectious agents including bacteria, viruses, protozoa, cestodes, nematodes and prions; ii) natural toxins including amanita toxins, tetrodotoxin, ciguatera and scombroid; iii) anaphylaxis; iv) poisoning; v) mechanical issues around airway and gut obstruction and/or perforation; and vi) miscellaneous causes. Food-related deaths are important in terms of global mortality, and thus autopsies need to be comprehensive with full ancillary testing. Medicolegal matters may involve issues concerning likely exposure to infectious agents, possible foods ingested, the declared content and possible components of food, the significance of toxicological analyses, and aspects of duty of care in cases of café coronary syndrome and gastroenteritis while in care.

Background: Esophageal perforations and postoperative leakage of esophagogastrostomies are considered to be life-threatening conditions due to the potential development of mediastinitis and consecutive sepsis. Vacuum-assisted closure (VAC) techniques, a well-established treatment method for superficial infected wounds, are based on a negative pressure applied to the wound via a vacuum-sealed sponge. Endoluminal VAC (E-VAC) therapy as a treatment for GI leakages in the rectum was introduced in 2008. E-VAC therapy is a novel method, and experience regarding esophageal applications is limited. In this retrospective study, the experience of a high-volume center for upper GI surgery with E-VAC therapy in patients with leaks of the upper GI tract is summarized. To our knowledge, this series presents the largest patient cohort worldwide in a single-center study., Methods: Between October 2010 and January 2017, 77 patients with defects in the upper gastrointestinal tract were treated using the E-VAC application. Six patients had a spontaneous perforation, 12 patients an iatrogenic injury, and 59 patients a postoperative leakage in the upper gastrointestinal tract., Results: Complete restoration of the esophageal defect was achieved in 60 of 77 patients. The average duration of application was 11.0 days, and a median of 2.75 E-VAC systems were used. For 21 of the 77 patients, E-VAC therapy was combined with the placement of self-expanding metal stents., Conclusion: This study demonstrates that E-VAC therapy provides an additional treatment option for esophageal wall defects. Esophageal defects and mediastinal abscesses can be treated with E-VAC therapy where endoscopic stenting may not be possible. A prospective multi-center study has to be directed to bring evidence to the superiority of E-VAC therapy for patients suffering from upper GI defects.

Objective: The aim of this study is to discuss the clinical presentation, imaging examination and treatment of neck abscess and mediastinal abscess following esophageal perforation induced by esophageal foreign body. Method: Six patients all underwent lateral neck incision and drainage of neck abscess. Simultaneously, mediastinal abscess drainage was performed in 3 cases with mediastinal abscess. Result: All 6 patients were cured. The median time of extraction of gastric tube was 11 days (7-30 days). All patients were not treated with tracheotomy. Conclusion: Neck and chest CT should be done as soon as possible for suspected patients to definite the location of foreign body and the relationship between foreign body and surrounding structures. Patient who were suspected with neck abscess and mediastinal abscess should undergo surgery to remove foreign body and drain the infectious deep neck and mediastinal spaces as early as possible.

We describe a 47-year-old male who was admitted to our centre from a local emergency unit with septic shock due to suspected Boerhaave syndrome. After the diagnosis was confirmed, the patient underwent emergency surgery. Postoperatively, the patient had symptoms of acute alcoholic delirium, and developed an oesophagomediastinal fistula as the most serious local complication. Successful conservative treatment enabled complete healing of the fistula, leading to patient recovery. No late complications like oesophageal stenosis were found at 6 months from discharge.

Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368) and the in-hospital mortality was 17% (61/368). The current literature suggests that a SEMS-based therapy can be successfully applied as an alternative therapeutic strategy in esophageal perforation rupture., (© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)