Mackler’s triad: Boerhaave syndrome

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. Acknowledgements The authors wish to acknowledge Willem J. Thijs (Department of Gastroenterology) and Caroline H.C. Janssen, MD (Department of Radiology) for their kind assistance. Disclosures All authors declare no conflict of interest. No funding or financial support was received

Mackler’s triad:Boerhaave syndrome

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. Acknowledgements The authors wish to acknowledge Willem J. Thijs (Department of Gastroenterology) and Caroline H.C. Janssen, MD (Department of Radiology) for their kind assistance. Disclosures All authors declare no conflict of interest. No funding or financial support was received

Effectiveness of treatment for octogenarians with acute abdominal aortic aneurysm

Objective:To investigate whether advanced age may be a reason to refrain from treatment in patients with an acute abdominal aortic aneurysm (AAAA).Methods:This was a retrospective cohort study that took place in a tertiary care university hospital with a 45-bed intensive care unit. Two hundred seventy-one patients with manifest AAAA, admitted and treated between January 2000 and February 2008, were included. Six patients died during operation and were included in the final analysis to ensure an intention-to-treat protocol, resulting in 234 men and 37 women with a mean age of 72 ± 7.8 years (range, 54-88 years). Forty-six patients (17%) were 80 years or older. Interventions involved open or endovascular AAAA repair.Results:Mean follow-up was 33 ± 30.4 months (including early deaths). Mean hospital length of stay was 16.9 ± 20 days for patients younger than 80 and 13 ± 16.7 days for patients older than 80 years of age. Kaplan-Meier survival analysis revealed a significantly better survival for the younger patients (P < .05). Stratification based on urgency or type of treatment did not change the difference. Two-year actuarial survival was 70% for patients younger than 80 and 52% for those older than 80. At 5-year follow-up, these figures were 62% and 29%, respectively. Mean survival in patients older than 80 was 39.8 ± 6.8 months versus 64.5 ± 3.0 months in those younger than 80.Conclusions:For octogenarians, our liberal strategy of treating patients with AAAA was associated with satisfactory short- and long-term outcome, with no difference with regard to disease- or procedure-related morbidity between the younger and older group. Assuming an integrated system for managing AAAA is in place, advanced age is not a reason to deny patients surgery

Procalcitonin-Guided Antibiotic Prescription in Patients With COVID-19:A Multicenter Observational Cohort Study

BACKGROUND: Despite the low rate of bacterial coinfection, antibiotics are very commonly prescribed in hospitalized patients with COVID-19. RESEARCH QUESTION: Does the use of a procalcitonin (PCT)-guided antibiotic protocol safely reduce the use of antibiotics in patients with a COVID-19 infection? STUDY DESIGN AND METHODS: In this multicenter cohort, three groups of patients with COVID-19 were compared in terms of antibiotic consumption, namely one group treated based on a PCT-algorithm in one hospital (n = 216) and two control groups, consisting of patients from the same hospital (n = 57) and of patients from three similar hospitals (n = 486) without PCT measurements during the same period. The primary end point was antibiotic prescription in the first week of admission. RESULTS: Antibiotic prescription during the first 7 days was 26.8% in the PCT group, 43.9% in the non-PCT group in the same hospital, and 44.7% in the non-PCT group in other hospitals. Patients in the PCT group had lower odds of receiving antibiotics in the first 7 days of admission (OR, 0.33; 95% CI, 0.16-0.66 compared with the same hospital; OR, 0.42; 95% CI, 0.28-0.62 compared with the other hospitals). The proportion of patients receiving antibiotic prescription during the total admission was 35.2%, 43.9%, and 54.5%, respectively. The PCT group had lower odds of receiving antibiotics during the total admission only when compared with the other hospitals (OR, 0.23; 95% CI, 0.08-0.63). There were no significant differences in other secondary end points, except for readmission in the PCT group vs the other hospitals group. INTERPRETATION: PCT-guided antibiotic prescription reduces antibiotic prescription rates in hospitalized patients with COVID-19, without major safety concerns

Prognostic Value of Resection of Primary Tumor in Patients with Stage IV Colorectal Cancer: Retrospective Analysis of Two Randomized Studies and a Review of the Literature

Item does not contain fulltextBACKGROUND: In patients with metastatic colorectal cancer (mCRC) with an asymptomatic primary tumor, there is no consensus on the indication for resection of the primary tumor. METHODS: A retrospective analysis was performed on the outcome of stage IV colorectal cancer (CRC) patients with or without resection of the primary tumor treated in the phase III CAIRO and CAIRO2 studies. A review of the literature was performed. RESULTS: In the CAIRO and CAIRO2 studies, 258 and 289 patients had undergone a primary tumor resection and 141 and 159 patients had not, respectively. In the CAIRO study, a significantly better median overall survival and progression-free survival was observed for the resection compared to the nonresection group, with 16.7 vs. 11.4 months [P < 0.0001, hazard ratio (HR) 0.61], and 6.7 vs. 5.9 months (P = 0.004; HR 0.74), respectively. In the CAIRO2 study, median overall survival and progression-free survival were also significantly better for the resection compared to the nonresection group, with 20.7 vs. 13.4 months (P < 0.0001; HR 0.65) and 10.5 vs. 7.8 months (P = 0.014; HR 0.78), respectively. These differences remained significant in multivariate analyses. Our review identified 22 nonrandomized studies, most of which showed improved survival for mCRC patients who underwent resection of the primary tumor. CONCLUSIONS: Our results as well as data from literature indicate that resection of the primary tumor is a prognostic factor for survival in stage IV CRC patients. The potential bias of these results warrants prospective studies on the value of resection of primary tumor in this setting; such studies are currently being planned