Boerhaave Syndrome with Right-Sided Hydropneumothorax Associated with Cannabinoid Hyperemesis Syndrome: Combined Endoscopic Stenting and Video-Assisted Thoracoscopic Surgery
Shubhendu Bajpai, Abdullah Sultany, Akshay Raut, Andrew Vela, Kevin Carroll, Keertana Seeli, Joseph Cahill, Faraz SiddiquiAbstract
Introduction:
Boerhaave syndrome, spontaneous transmural esophageal rupture, carries a mortality rate of 12% to 16% that rises sharply with diagnostic delay. Right-sided pleural involvement from distal perforation is uncommon and may obscure recognition. Cannabinoid hyperemesis syndrome (CHS) is rarely reported as a precipitant, and evidence for hybrid endoscopic stenting and video-assisted thoracoscopic surgery (VATS) remains limited.
Case Presentation:
A cachectic middle-aged man (body mass index 16.8 kg/m²) with CHS and Los Angeles grade D esophagitis was admitted for altered mental status with persistent vomiting. On hospital day 2, he developed chest pain, dyspnea, and hypoxemia (SpO₂ 87% on 10 L/min), with absent right-sided breath sounds and hemodynamic instability. Chest radiography demonstrated a right hydropneumothorax with mediastinal shift. Needle decompression and tube thoracostomy yielded 1.2 L of purulent fluid with polymicrobial gastrointestinal flora. Computed tomography with oral contrast confirmed distal esophageal perforation with right pleural extravasation. Endoscopy identified a 1 cm defect 2 cm proximal to the gastroesophageal junction, treated with a 12 cm covered stent followed by right VATS decortication and washout. The postoperative course was complicated by mucus plug–related respiratory failure requiring reintubation, empyema, and acute kidney injury, all resolving with supportive care. Contrast imaging confirmed esophageal patency without leak.
Discussion:
This case highlights 3 uncommon features: right-sided hydropneumothorax from a distal perforation, CHS as a precipitant, and delayed recognition from a nonthoracic initial presentation. Hybrid stenting with VATS achieved esophageal healing and source control while avoiding thoracotomy. Esophageal perforation warrants consideration in patients with new hydropneumothorax, polymicrobial pleural infection, or acute thoracic deterioration after protracted vomiting, irrespective of laterality.