Rare case of cocaine, cannabis and alcohol induced vomiting leading to Boerhaave syndrome

Oesophageal perforations are rare, with an incidence of 3.1 per 1,000,000 per year. Boerhaave syndrome is associated with high morbidity and mortality and is fatal in the absence of therapy. The occasionally nonspecific nature of the symptoms may contribute to a delay in diagnosis and a poor outcome. We present a case study of the above with cocaine and substance abuse leading to rupture of oesophagus. A 31-year-old male was brought to the emergency department by London ambulance during COVID with abdominal pain. The ED staff was informed that the patient experienced chronic diarrhoea and vomiting because of cocaine, cannabis, and alcohol usage.
Patient presented with vomiting, chest, neck pain and had evidence of subcutaneous emphysema. On auscultation patient also had a crunching noise synchronised with the heartbeat (Hamman's sign). Patient was urgently referred to surgeons and a fast access CT Chest, Abdo, Pelvis was performed. A diagnosis of Boerhaave syndrome/ oesophageal perforation was made. Treatment: Antifungals and antibiotics to help prevent sepsis from acute mediastinitis.
Mackler's triad is a rare condition and not all patients present with Boerhaave or oesophageal rupture. This patient had a history of heavy vomiting to the point where there was severe chest pain, and streaks of blood in the vomitus. Our case demonstrates the clinical high yield value in concreate history taking, examination, alongside targeted image modalities in diagnosis of this syndrome as misdiagnosis has catastrophic implications for the patient. Should an insistent vomiter come in with chest pain, Boerhaave should always be considered.
 

Keywords: Gastro-oesphageal reflux disease, Boerhaave syndrome, heavy vomiting, Mackler triad, mediastinitis, emphysema.