Mackler’s triad: Boerhaave syndrome

Hjalmar Bouma, Margot L. J. Scheer

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A 58-year-old man with a history of alcohol abuse presented
after three days of nausea and vomiting with mild (pleuritic)
chest pain and diffuse abdominal pain. The patient had no
other remarkable symptoms and vital signs and the remainder
of the physical examination was normal. The initial workup in
the emergency department, at night, included a chest X-ray
(figure 1A) and an arterial blood gas analysis, which revealed no
gross abnormalities except mild hypoxaemia. The differential
diagnosis at that moment included pulmonary embolism.
The patient received therapeutic anticoagulation and was
scheduled for a CT angiography the next morning. However,
the next morning, his chest pain deteriorated acutely and he
developed progressive severe respiratory distress. A fluctuating,
crepitating swelling was noted in his neck. The presence of
subcutaneous emphysema and mediastinal widening with
increased radiolucency suggestive of a pneumomediastinum
was revealed by chest X-ray (figure 1B). Although the patient
had not vomited since the initial presentation to our hospital
several hours earlier, Boerhaave syndrome was suspected.
Classically, Boerhaave syndrome presents as Mackler’s triad,
which consists of (1) vomiting followed by (2) chest pain and (3)
subcutaneous emphysema due to an oesophageal rupture.
A CT scan (figure 1C) demonstrated air surrounding the
aorta (arrow), subcutaneous emphysema (arrow heads) and a
pneumothorax (yellow arrow). A small amount of oral contrast
was used to confirm the suspected oesophageal rupture, which
was located in the right dorsolateral region above the cardia.
Based on these findings, Boerhaave syndrome was diagnosed.
The patient developed septic shock syndrome with multipleorgan
failure and was treated with vasopressive medication
and broad-spectrum antibiotics. In addition, he required
invasive ventilation, continuous veno-venous haemofiltration
and bilateral chest tube drainage. The oesophageal tear
was endoscopically stented and later restented due to stent
dislocation. After two months on the ICU, the patient had
recovered enough to be transferred to a rehabilitation clinic.
The authors wish to acknowledge Willem J. Thijs (Department of
Gastroenterology) and Caroline H.C. Janssen, MD (Department
of Radiology) for their kind assistance.
All authors declare no conflict of interest. No funding or
financial support was received.
Original languageEnglish
Number of pages1
JournalNetherlands Journal of Critical Care
Issue number1
Publication statusPublished - Jan-2016

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