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TREATMENT

■ In the ED, immediate broad spectrum antibiotics should be started.

■ Antibiotics should cover Staphylococcus,Streptococcus,Pseudomonas, and

Bacteroides.

■ The majority of perforations are treated surgically; therefore, a surgical

consult should be immediately requested.

■ Keep the patient NPO and treat shock with IV fluids and vasopressors if

necessary.

■ H2 blockers have no role in treatment of Boerhaave syndrome.

DISPOSITION

■ There is a 10% mortality rate when the disease is immediately recognized;

this↑to 50% survival when perforation has occurred >24 hours before ED

presentation.

■ Most patients will require ICU level of care.

ESOPHAGEALVARICES

Varices are dilated submucosal veins that become distended when portal pres-

sure is elevated. They are found in half of patients with ascites. One-third of

cases cause upper GI bleeding. (See also “Upper GI Bleeding.”)

SYMPTOMS

Usually presents as an upper GI bleed

TREATMENT

■ Bleeding may be life threatening; adequate fluid resuscitation with IV

fluids and blood products if needed

■ Over-resuscitation can increase portal pressure and increase rate of bleeding

(hematocrit >30% is associated with elevated portal pressures).

■ Coagulopathic patients may require FFP or platelets.

■ IV octreotide

■ IV antibiotics (third-generation cephalosporin or floroquinolone)

■ Balloon tamponade (Sengstaken-Blakemore and Minnesota tubes) may

be used to stop hemorrhage. Strongly advise prior airway protection.

■ Emergent endoscopy is needed for banding or sclerotherapy of bleeding varices.

DISPOSITION

■ In-house mortality rates are 15%.

■ Patients require ICU care.

ACHALASIA

SYMPTOMS

Dysphagia, odynophagia, regurgitation of undigested food

DIFFERENTIAL

Spasm, stricture, tumor

DIAGNOSIS

Bird’s beakon barium swallow, dilation of upper esophagus with narrowing

at cardioesophageal junction (see Figure 11.2).

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

FIGURE 11.2. Acha-

lasia seen on barium

swallow.

(Reproduced, with permis-

sion, from Chen MYM,

Pope TL, Ott DJ. Basic

Radiology. New York:

McGraw-Hill, 2004:258.)