title: Boerhaave's syndrome in a patient with an upside down stomach: A case report.
abstract: BACKGROUND
  Spontaneous esophageal perforation, or Boerhaave's syndrome, is a life-threating condition which usually requires emergent surgery. An upside down stomach is defined as a gastric volvulus in a huge supradiaphragmatic sac. In general, this condition can result in ischemia and perforation of the stomach. This is the first report of a patient with Boerhaave's syndrome and an upside down stomach.
  
  
  METHODS
  A 79-year-old woman presented with sudden epigastric pain following hematemesis. Evaluation of the patient showed both an esophageal perforation and an upside down stomach. Surgical drainage and irrigation of the mediastinum and pleural cavities were undertaken emergently. Due to the concurrent gastric volvulus, a gastrostomy was placed to fix and decompress the stomach. The patient had an uneventful hospital course and was discharged.
  
  
  CONCLUSIONS
  Boerhaave's syndrome is a rare but severe complication caused by excessive vomiting, due to a sudden elevation in intraluminal esophageal pressure resulting in esophageal perforation. Acute gastric volvulus can result in ischemia and perforation of the stomach, but has not previously been reported with esophageal perforation. The most likely mechanism associating an upside down stomach with Boerhaave's syndrome is acute gastric outlet obstruction resulting in vomiting, and subsequent esophageal perforation. Perforation of the esophagus as well as perforation of the stomach must be considered in patients with an upside down stomach although both upside down stomach and Boerhaave's syndrome are rare clinical entities.
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: shin.s@jichi.ac.jp.
authors.forename: Shin
authors.initials: S
authors.lastname: Saito
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: hosoyo@jichi.ac.jp.
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Hosoya
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: kurashonan@jichi.ac.jp.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Kurashina
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: s-matsumoto@jichi.ac.jp.
authors.forename: Shiro
authors.initials: S
authors.lastname: Matsumoto
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: rkanamaru@jichi.ac.jp.
authors.forename: Rihito
authors.initials: R
authors.lastname: Kanamaru
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: ui@jichi.ac.jp.
authors.forename: Takashi
authors.initials: T
authors.lastname: Ui
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: haruta511@yahoo.co.jp.
authors.forename: Hidenori
authors.initials: H
authors.lastname: Haruta
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: kitayama@jichi.ac.jp.
authors.forename: Joji
authors.initials: J
authors.lastname: Kitayama
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: alefor@jichi.ac.jp.
authors.forename: Alan K
authors.initials: AK
authors.lastname: Lefor
authors.affiliation: Department of Surgery, Jichi Medical University, Tochigi, Japan. Electronic address: sata@jichi.ac.jp.
authors.forename: Naohiro
authors.initials: N
authors.lastname: Sata
keywords: Boerhaave’s syndrome; Gastronomy; Upside down stomach