Disama dia Boerhaave: Dinyanguka dia tshiadi tshia munda mua tshifu kunyima kua dibutuka dia bukole, disama dia Mackler, ne disama dia Hamman dia tshitupa tshia munda tshia mubidi¶

Boerhaave syndrome (spontane barogenic transmural rupture of the esophagus) i disama dia mu tshifu didi dishipangana bikole mu buanga bua mu lupitadi, didi ne bungi bua bantu badi bafua kabayi baondapibua pabuipi ne 100 pa lukama ne bungi bua bantu badi bafua bua bungi bua bantu badi bafua padibu bapanda anyi balongolola tshiamu tshia endoscopie panyima pa mêba 24**. Bishilangane na Mallory-Weiss tear, udi ditapuluka dia pa mutu dia mutantshi mule didi dishikila anu ku tshitupa tshia munda tshia mucose wa gastro-esophageal junction tshidi tshienza bua mashi apatuke kakuyi kanyinganyinga (hematemesis) ne adi wondopa nkayawu mu 90 pa lukama ya bilumbu, Boerhaave syndrome udi dibutuka dia mubidi mujima (trans-mural) kupitshila ku dibutuka dia mashi onso tshimanu tshia tshifu, tshidi tshienzeka mu 90 pa lukama ya bilumbu ku tshimanu tshia ku dia bakaji tshia tshitupa tshisatu tshia tshifu tshia mu tshiadi, 2 too ne ku 4 santimetre (0,8 too ne ku 1,6 inches) pa mutu pa tshitupa tshia tshifu. Didi dijuka padi tshisumi tshia munda mua tshifu tshienda tshivula, padi muntu wela manyi bikole (nangananga padi muntu uteta bua kukanda anyi kukanda tshifu tshidi tshikanga tshifu), tshifu tshikole, dibandisha dia bujitu bua bungi, anyi dilela dia muana bidi bibueja aside wa mu tshifu, enzyme ya digestion, kapepe ka mu tshifu, ne bitupa bia biakudia mu tshimanu tshia mu tshifu mediastinum wa panyima ne tshitupa tshia ku dia bakaji tshia pleure tshidi katshiyi tshilela. Mu meba makese, aside wa mu tshifu ne bactérie ya mukana bidi bijula ​​mediastinite necrotisante wa tshimpitshimpi ne wa bactérie, tension hydropneumothorax, ne refractory septic shock. Shi muntu yonso udi mufuma ku diela anyi mupue ku bukole umvua disama dia tshimpitshimpi, dia tshimpitshimpi, dia tshifu tshia kuinshi anyi dia kuulu dia difu, dipanga dia mupuya, anyi bipupu bia kapepe bidi muinshi mua dikoba dia nshingu wende (Mackler's triad), ubikile muaba unudi nomba ya tshimpitshimpi diakamue. Tangila kabidi mikanda yetu ya bana betu pa mashi adi apatuka mu tshifu, mashi adi apueka, ne melena, dikosolola dia aorte ne ditapa dia aneurysme wa aorte wa mu difu, ne sepsis ne septic shock.

Tshiudi ne bua kuenza tshia kumpala ntshia kumanya disama dikole dia mu tshiadi dia ku tshiadi anyi dia ku dia bakaji dia diakamue panyima pa dipuekesha dia bukole anyi dipuekesha dia mishiku, kulama mubedi NPO (kakuyi tshintu tshia ku mishiku: nansha dikopo dimue dia mâyi, antacide, anyi tshitupa tshia mashika) bualu ditontolola dionso diudi umina didi dipatuka buludiludi mu tshifu tshidi tshinyunguluke tshiadi, kutangila nshingu ne mifuba ya ku nshingu bua emphyseme wa muinshi mua dikoba (Bubble-Wrap crackling under the fingers), ne kumanyisha "Suspected Boerhaave Esophageal Rupture" kudi bafidi ba diambuluisha dia lukasa ne baminganga ba triage bua CT esophagogramme anyi water-soluble contrast swallow () udi ne mushinga wa bungi Dididishi dia or dia dipanda dia mêba 24.

Enza nunku mpindieu¶

1. Bikila nimero ya tshimpitshimpi ya muaba uudi musombele diakamue pikala disama dikole dia mu tshiadi, dia mukolo anyi dia mu tshiadi dikuate mu tshikondo tshia anyi panyima pa wewe mumane kuela nsukadi anyi kuela nsukadi. Ela 911 mu États-Unis ne mu Canada, 999 mu Royaume-Uni, 112 mu Union européenne mujima, 000 mu Australie, anyi tangila mukanda wetu wa malu a pa buloba bujima nomba ya tshimpitshimpi. Amba patoke ne: "Mubedi udi ne disama dia tshimpitshimpi dia mu tshiadi diakamue panyima pa yeye mumane kuela nsukadi bikole; tuasakidila bua kumukonkonona bua kumanya ni udi ne disama dia Boerhaave esophageal rupture."
2. Kulekela mubedi unua mayi, umina bintu bidi bishipa acide, unua bipese bia mashika, anyi unua manga a disama dia mukana. Padi tshimanu tshia mu tshifu tshipatuka, tshifu katshiena kabidi tshintu tshikanga tshidi tshiya mu tshifu to; mayi onso, antacide, nansha manga adi mubedi umina adi apatuka mu tshitupa tshia munkatshi ne tshia mu tshiadi tshidi tshinyunguluke mifuba ne mutshima, bienza bua se mediastinite ne empyema ikale ne lufu lukasa.
3. Kulenga kuinshi kua nshingu, tshitupa tshia ku mutu kua nshingu, ne pa mutu pa mifuba ya nshingu bua kumona "Rice Krispies / Bubble-Wrap" udi ulenga muinshi mua dikoba (Cervical Subcutaneous Emphysema). Fina bitekete bitekete nsongo ya minu yebe kuinshi kua nshingu ne ku nseke ya nshingu anu pa mutu pa nshingu. Kumvua tupepele tukese tudi tuenda tunyanguka muinshi mua dikoba, pamue ne dishintuluka dia dîyi dia mubedi dia mu mishiku anyi dia mutoyi mukole (rhinolalia), didi dijikija Mackler's triad (kuela + disama dia mu tshiadi tshia kuinshi + emphysème wa muinshi mua dikoba dia mu tshifu) ne didi disama dia mu tshifu anyi dia mu tshiadi.
4. Teka mubedi mululame anyi mu tshitupa tshia Fowler tshia 45-degree (anyi mu muaba wende wa bupole muiname kakese kumpala); KUBEDI pa buloba to. Kusomba mululame kudi kuenza mudimu ne bukole budi bukokela bintu panshi bua kukepesha dipingana dia bintu bia mu tshifu bidi ne aside mu tshifu kupitshila mu tshitupa tshia muinshi tshia tshifu tshibuela mu tshifu ne kudi kuenza bua dipuyakana dikale dipepele pikala disama dia mu tshiadi tshia ku dia bakaji anyi dia pneumothorax difinakaja mifuba.
5. Teleja kumpala kua tshiadi bua kumvua mutoyi wa dikuma anyi wa dikuma udi umvuangana ne dikuma dia mutshima (Tshimanyinu tshia Hamman / Dikuma dia Hamman dia munkatshi). Padi kapepe ka tshianana kapatuka mu tshitupa tshia mu tshifu tshidi tshipanduluke mu tshitupa tshia munda tshidi tshinyunguluke tshibombi tshia pericarde, dikokangana dionso dia mutshima udi ukuma didi difina kapepe, dipatuisha mutoyi wa dikuma anyi wa dikuma, anyi dikuma dia mutshima mutoyi wa dikuma udi umvuika ne tshiamu tshia kuteleja natshi (ne imue misangu ne ditshi dia patupu pabuipi ne tshiadi), nangananga padi mubedi muimanyine kakese ku luseke luende lua dia bakaji.
6. Kupangisha disama dia tshiadi ne kudimuija bantu badi mu lupitadi bua kubenga kupitshila mu tshiamu tshia nasogastrique (NG) tshidi katshiyi tshimueneka. Baminganga ba lupitadi ne baminganga ba malu a mpukapuka badi ne bua kufila diakamue malu adibu bafila mu mijilu (bu mudi IV ondansetron 4 too ne ku 8 mg) bua disama dikuabu dia tshiadi kadiyi ditshibula dikasa dikole to. Dimuija bena mudimu ba mu lupitadi kubenga kupitshila mu tshiamu tshia nasogastrique tshidi katshiyi tshimueneka kumpala kua kuenza tshimfuanyi, bualu tshiamu tshia NG tshia plastique tshikole tshidi mua kupitshila anu mu tshitupa tshia esophage mu mediastinum anyi mu aorte.

Mutshi wa dipangadika: disama dia mu tshiadi anyi dia mu tshifu tshia panyima pa difu ne disungula dia mashi¶

flowchart TD
    A["Kuela nsukadi ku bukole, kuela nsukadi, anyi kukanda nsukadi idi ilonda kudi bimanyinu bikola"] --> B{"Ntshinyi tshidi tshileja tshimanyishilu tshia kumpala diakamue kunyima kua disama dia nsukadi?"}
    B -->|Sudden, agonizing tearing lower retrosternal or left chest pain radiating to left shoulder/back + shortness of breath + minimal or moderate blood| C["BUALU BUA BUALU BUA BOERHAAVE SYNDROME (Transmural Esophageal Rupture)"]
    B -->|Painless (or mild burning) vomiting of bright red blood streaks or clots after repeated retching; NO tearing chest pain, NO dyspnea, normal lung exam| D["Bidi mua kuikala ne disama dia Mallory-Weiss (dipanda dia mubidi wa pa mutu pa GE Junction)"]
    B -->|Massive, painless projectile vomiting of large volumes of dark/bright red blood in a patient with liver cirrhosis, jaundice, or ascites| E["Disama dia mu tshifu anyi dia mu tshifu (disama dia tshimpitshimpi dia mashi a bungi mu tshifu)"]
    C --> F{"Tangila bimanyinu bia Mackler's Triad, Hamman's Crunch, ne Left Pleural Signs"}
    F -->|Cervical subcutaneous emphysema crackles in neck OR Hamman's mediastinal crunch OR decreased left breath sounds / shock| G["DITUPA DIA MEDIASTINAL DIDI DISHINDIKIBUE: Bikila 911/999/112 diakamue"]
    F -->|Neck crackles absent (present in < 50% early on), but severe tearing chest/epigastric pain persists after vomiting| G
    G --> H["Ikala ne NPO (Kakuyi mayi/biakudia/maluvu); Ikala mululame ku 45 degre; Pesha IV Ondansetron + 2 Large-Bore IVs + Broad-Spectrum IV Antibiotics + IV PPI"]
    H --> I["Tshipiminu tshia or tshia lupitadi: CT tshia tshiadi/tshifu ne tshiamu tshia oral Water-Soluble Contrast (Gastrografin) OR Fluoroscopic Gastrografin Kuanji kumina (pashishe Thin Barium pikalabi bibi)"]
    I --> J{"Tshikondo tshipita katshia ku ditshibuka ne bungi bua dinyanguka dia mu tshitupa tshia munda anyi tshia mu tshiadi anyi?"}
    J -->|Diagnosed < 24 Hours: Contained or early uncontained leak| K["GOLDEN 24-HOUR WINDOW: Primary Two-Layer Surgical Repair by Left Thoracotomy/VATS (anyi Covered Self-Expanding Metal Stent + Thoracoscopic Drainage)"]
    J -->|Diagnosed > 24 to 48 Hours: Friable necrotic esophageal edges & severe septic empyema| L["Dipanda dia tshimpitshimpi, dipanda dia munda mua tshiadi, dilongolola dia endoluminal (EndoVAC) anyi T-Tube, ne dipanda dia jejunostomie"]
    D --> M["Dikonkonona dia ED dia mu lupitadi: IV PPI + IV Ondansetron + CBC/Type & Screen + Upper Endoscopy (EGD) munda mua mêba 24 (90% stop spontaneously)"]
    E --> N["Dilengeja dia lukasa: IV Octreotide/Terlipressin + IV Ceftriaxone + Dikanga dia lukasa dia tshiamu tshia mitaku"]

Tshilejelu tshia mubidi ne tshia biomecanique: bua tshinyi 90% ya binsonji bia Boerhaave bidi bitshibula tshitupa tshia ku dia bakaji tshia posterolateral distal esophagus¶

Bua musangu wa kumpala mu 1724 kudi munganga wa mu Pays-Bas Herman Boerhaave kunyima kua Grand Admiral wa mazuwa a Pays-Bas, Baron Jan van Wassenaer, mumane kupeta tshipupu tshikole kunyima kua difesto dikole ne mufue kunyima kua mêba 18 ne nkutshi mioshe ne mvinyo mu tshiadi tshiende tshia ku dia bakaji, Boerhaave is syndrome baroeïque (driven) dibutuka.

1. Dipanga dia diumvuangana dia mishipa ya mu tshiadi tshia kuulu (Cricopharyngeus)¶

Mu tshikondo tshia diela dia pa tshibidilu, tshitupa tshia buongo tshidi tshilongolola bulongame: pylorus udi ujika, tshimanu tshia difu ne diaphragme bidi bikola, sphincter wa kuinshi wa esophage (LES) udi ulekela, ne sphincter wa esophage wa kuulu (cricopharyngeus muscle) udi ulekela bimpe menemene pambelu pa tshifu mukana. Mu disama dia Boerhaave, misangu ya bungi padi muntu wenda utua mishiku misangu ne misangu kunyima kua kunua maluvu anyi kudia biakudia bia bungi, anyi udi ukanga nshingu wende bua kubenga kuela nsukadi kumpala kua bantu, misunya ya mu difu ne diaphragme idi idikosa ne bukole bua bungi (ivulangana mu tshifu ne mu tshifu pa mutu pa 30 mm), eku **300 Hg mushipa wa cricopharyngeus udi ku mutu kua tshifu udi upanga kuikisha. Bu mudiye mukuatshike pankatshi pa tshintu tshikole tshidi tshipatuka mu tshifu ne tshitupa tshia kuulu tshidi tshikanga ku nshingu, tshitupa tshia munda tshidi tshipatuka bu tshintu tshia munda tshidi tshiuwule tente.

2. Bua tshinyi ditshibuka ditu dienzeka misangu yonso ku tshimanu tshia ku dia bakaji (2 too ne ku 4 cm pa mutu pa diaphragme)¶

Pa mutu pa 90 pa lukama ya ditapa dia tshiadi tshia mu tshiadi didi dienzeka bu ditapuluka dia mu bule (didi ne bule bua 1 too ne ku 8 santimetre [0,4 too ne ku 3,1 inches]) ku **tshitupa tshia ku dia bakaji tshia tshiadi tshia munda mua tshifu, 2 too ne ku 4 santimetre pa mutu pa tshitupa tshia tshiadi:

ANATOMICAL VULNERABILITY OF THE LEFT POSTEROLATERAL DISTAL ESOPHAGUS
=======================================================================
                       [Upper Esophageal Sphincter]
                    (Cricopharyngeus FAILS TO RELAX)
                                  ||
                                  ||  <-- Trapped High-Pressure Column
                                  ||      (200 to 300 mmHg Surge)
       Right Chest                ||                Left Chest
   (Protected by Azygos           ||            (UNSUPPORTED WALL:
    Vein & Right Pleura)          || ===> * ===>  90% OF RUPTURES
                                  ||   2-4 cm     OCCUR HERE)
                                  ||  Above GEJ        |
   ------------------------[Diaphragm Hiatus]----------+---------------
                                 /  \                  v
                                |    |       Gastric Acid, Pepsin, Bile,
                                |    |       Food & Oral Anaerobes Pour
                             [Stomach]       Directly Into Posterior
                                             Mediastinum & Left Pleura
=======================================================================

Butekete bunayi bua mubidi budi bupetangana mu tshitupa etshi tshia 3-centimètre ku dia bakaji dia posterolateral distal esophagus: 1. Dikepesha ne ditekesha dia mishipa ya mu tshifu: Tshilamba tshia mu tshifu tshia mu tshifu tshidi tshikepela ne tshitapuluka mu bitupa bidi bitangalake anu pa mutu pa tshitupa tshia mu tshifu tshia kuinshi. 2. Dibutuka dia mijilu (Loci Minoris Resistentiae): Matamba a mushipa wa tshifu tshia ku dia bakaji ne wa vague nerve adi atobola muscularis propria muaba eu menemene, bienza miaba mitekete ya mu tshifu. 3. Angulation at the Diaphragmatic Hiatus: Padi esophagus wenda uya kumpala ne ku dia bakaji bua kupitshila mu diaphragmatic crura, bukole bua hydraulique budi buenda bubanda buludiludi mu tshitupa tshia ku dia bakaji tshia posterolateral bend. 4. Dipanga dia bitupa bia mubidi bidi pabuipi ku dia bakaji: Padi tshifu tshia ku dia balume tshia kuinshi tshikolesha pambelu kudi mukolo, aorte udi upueka, ne pleura wa munkatshi, tshimanu tshia ku dia bakaji tshia tshifu tshia kule tshidi tshilamakaja buludiludi ne pleura wa ku dia bakaji udi kayi ne tshintu tshikole tshidi tshikuatshisha, bienza bua binsonji bibuele buludiludi mu ** pleure ** mu 75 to ne 80 pa lukama ya babedi.

Dishilangana dia disama dia ku luseke ne ku luseke: Disama dia Boerhaave ne Mallory-Weiss Tear vs Ruptured Esophageal Varices vs Thoracic Aortic Dissection¶

Dileja dia mu lupitadi: Mackler's Triad, Hamman's Sign, ne pleural Effusion progression¶

Bualu bua Mackler's triad udi mu tshibungi tshia 14 too ne ku 50 pa lukama tshia babedi mu mêba makese a kumpala, kuindila bimanyinu bionso bisatu kumpala kua kulomba CT esophagogramme kudi kufikisha ku lufu ludi mua kuepuka. Umvua mudi tshimanyinu tshionso tshienda tshishintuluka mu bule bua matuku:

1. Bitupa bisatu bia Mackler's Triad¶

1. Difuka dia bukole anyi dipuekesha: Pa tshibidilu didi dilua kumpala kua kanyinganyinga mu tusekonde tukese. (Dimanyisha: Mu 10 too ne ku 15 pa lukama ya bilumbu, tshidi tshikebesha disama edi ntshia dikokola dia bukole, disama dia mputa, disama dia tshiadi, dibandisha dia bujitu, dienza dia malu a tshisuku, anyi kuseka pamutu pa kuela nsukadi.)
2. Disama dia tshimpitshimpi dia mu tshiadi tshia kuinshi anyi dia mu tshiadi: Disama dikole dia mu tshiadi anyi dia kuulu dia difu didi difika ku tshifu tshia ku dia bakaji, ku luseke lua dia bakaji, anyi ku nsongo ya dikaya dia bakaji (tshimanyinu tshia Kehr's phrenic nerve) padi mâyi a mu tshifu adi ne aside afika ku tshitupa tshia ku dia bakaji tshia diaphragme. Kumina anyi kuela mupuya mukola kudi kukolesha kanyinganyinga misangu dikumi (kanyinganyinga kakole ka odynophagie ne kanyinganyinga ka pleurite).
3. Cervical Subcutaneous Emphysema (Neck Crepitus): Lupepele ludi lumina ludi lupatuka kupitshila mu njila ya binsonji bia mu tshifu tshidi tshiya muulu mu njila ya periesophageal fascial ya kunyima kua mediastinum too ne ku base of the neck ne supraclavicular fossae. Nansha mudibi bimueneka ku tshiamu tshia CT mu dîba dimue kudi babedi 90 pa lukama, bipeta bia dikoba dia "Rice Krispies" bidi bimueneka ku luseke lua bulalu bidi bilomba mêba 1 too ne ku 6 bua kufika ku dikoba dia mu nshingu ne bidi biumvuika pa tshikebelu tshia kumpala mu bantu 30 anyi 60 pa lukama.

2. Tshimanyishilu tshia Hamman (Mediastinal Crunch) ne "V-Sign of Naclerio"¶

• Tshimanyinu tshia Hamman: Tshidi tshimueneka mu misangu mitue ku 20 pa lukama, etshi ntshiona tshikole, tshia dikuma, tshia dikuma, anyi tshia dibutuka didi diumvuika pa mutu pa tshitupa tshia kumpala tshia muoyo ne dikuma dionso dia mutshima padi mutshima ukuma ku mifuba ya kapepe ka mu tshitupa tshia munda (pneumomediastinum).
• Dikola dia lukasa dia Hydropneumothorax wa ku dia bakaji ne tshipupu tshia septique: Mu 2 too ne ku 6 mêba a ditshibuka, enzymes ya digestion (pepsin ne trypsin), hydrochloric acid, bile, ne bactérie anaérobie/aérobie ya mukana idi ipita mu pleure mediastinal wa ku dia bakaji. Mashi ne kapepe bidi bibuela mu tshiadi tshia ku dia bakaji (hydropneumothorax wa ku dia bakaji), bienza bua dikuma dia mu tshiadi tshia ku dia bakaji dikale dikole, dipanga dia mupuya wa ku dia bakaji, dishintuluka dia tshiadi tshiya ku dia balume, disama dia fièvre, tachycardie, dikoba dia mabala, ne fulminant septic shock.

Mukenji wa dipima dia masama mu lupitadi: Bua tshinyi tshintu tshidi tshinyanguka mu mayi (Gastrografin) tshidi ne tshia kulua kumpala kua barium, ne bua tshinyi endoscopy udi ne njiwu¶

Padi mubedi ufika ku tshibambalu tshia malu a mpukapuka ne disama dia Boerhaave, ba munganga badi benza tshikebelu tshikole tshia dikonkonona bua kujadika dibutuka dia munda kakuyi dikolesha dia disama dia mu mikolo anyi dienza dia pneumothorax wa tension:

1. X-Ray wa tshiadi tshilulame (tshiamu tshia kumpala, katshiena tshibenga Boerhaave nansha kakese)¶

Tshiamu tshia X-ray tshia mu tshiadi tshidi tshitangalake tshidi tshibi kudi babedi 85 too ne ku 90 pa lukama mu mêba makese, tshileja ne: - Dipatuka dia mashi mu tshiadi tshia ku dia bakaji (75% too ne ku 80%) anyi pneumothorax wa ku dia bakaji. - Pneumomediastinum: Milonda ya kapepe kafiike idi ileja tshitupa tshia aorte, pericardium, anyi idi yenza tshimanyinu tshia kale tshia V-tshimanyinu tshia Naclerio (mulongo wa kapepe ka mu tshimfuanyi tshia V udi kuinshi kua dia bakaji dia mediastinum muenza kudi kapepe kadibu bakuate pankatshi pa aorte thoracique udi upueka ne hemidiaphragme wa ku dia bakaji). - Emphysème wa muinshi mua dikoba dia mu tshifu udi ulonda mu bitupa bia mu nshingu. - Didimuija dia mushinga mukole: X-ray wa tshiadi mu meba 1 anyi 2 a kumpala kaena mua kumbusha disama dia Boerhaave to.

2. Tshipiminu tshia or: CT Esophagogramme ne tshiamu tshia fluoroscopique¶

CONTRAST SELECTION PROTOCOL FOR SUSPECTED ESOPHAGEAL RUPTURE
=======================================================================
STEP 1: Oral Water-Soluble Iodinated Contrast (GASTROGRAFIn / Iohexol)
        - Administered via CT Esophagogram or Upright Fluoroscopy.
        - WHY FIRST? If Gastrografin leaks out of the torn esophagus
          into the mediastinum or pleural cavity, the body safely absorbs
          water-soluble iodine without causing foreign-body fibrosis.
        - ASPIRATION CAUTION: In patients at high risk of aspirating into
          the lungs or tracheobronchial fistula, use Low-Osmolar Non-Ionic
          Water-Soluble Contrast (Iohexol / Omnipaque) rather than hyperosmolar
          Gastrografin (which can trigger chemical pulmonary edema if inhaled).
                                  |
                                  v
        Does Water-Soluble Contrast Show Extravasation (Leak)?
               /                                     \
     [YES: Leak Confirmed]                  [NO: Negative Swallow (15-20%
              |                              False-Negative Rate with Thin
              v                              Water-Soluble Contrast)]
     Proceed Directly to                              |
     Surgical / Endoscopic                            v
     Repair & Chest Tube               STEP 2: Immediate Follow-Up Swallow
                                               with Thin Diluted BARIUM
                                               (Higher mucosal coating density
                                                catches small contained tears)
=======================================================================

• Bua tshinyi barium sulfate mmukandika bikole bu tshintu tshia kumpala tshia difuanyikija: Shi barium sulfate mukola udi mufidibua kumpala ne mubuela mu tshitupa tshinene tshia mu tshifu mu tshitupa tshia panyima tshia mediastinum anyi tshia pleure, mubidi kawena mua kuangata barium to. Ma kristale a barium adi munda mua tshiadi adi afila disama dikole dia kashidi dia granulomatous foreign-body mediastinitis ne fibrosing pleuritis didi dipangisha tshimfuanyi tshia pashishe ne dikolesha dia sepsis wa dipanda. Misangu yonso, tuadija ne tshintu tshidi tshinyanguka mu mayi (anyi tshintu tshidi katshiyi ne ion tshidi tshinyanguka mu mayi bu mudi iohexol [Omnipaque] pikala dipuekesha dia mu mikolo didi ne njiwu), ne wenze mudimu anu ne barium mukese pikala didia dia kumpala didi dinyanguka mu mayi kadiyi dimpe nansha mudiku dielakana dia bungi.
• CT Chest and Upper Abdomen with Oral Water-Soluble Contrast (CT Esophagogram): Mu bibambalu bia matuku etu aa, CT Esophagogram udi ne bukole bua bungi kupita 92 too ne ku 98 pa lukama, udi wenza mudimu bimpe kupita fluoroscopie wa patupu mu babedi badi kabayi bashindame badi kabayi mua kuimana bua kumina, udi uleja tuishi tukese tua kapepe ne kapepe dikola dia tshimanu tshia mu tshifu nansha kumpala kua dipatuka dia tshiamu tshia mitaku, ne musangu umue didi dipangisha dipanda dia aorte thoracique, embolie pulmonaire, ne ulcère peptique perforée.
• Dikonkonona dia mayi a mu tshiadi (bikalabu bateka tshiamu tshia mu tshiadi): Padi tshiamu tshia tshiadi tshia ku dia bakaji anyi tshiamu tshia mu tshiadi tshipatula mâyi a mu tshiadi tshia ku dia bakaji mu disama dia Boerhaave, mâyi adi aleja bipese bia biakudia bidi kabiyi bimane kudia, pH wa mâyi a mu tshiadi adi muinshi mua 6,0 (afumina ku aside wa mu tshifu ** udi mubandile tshitupa tshia amylase tshia mu mate**.
• Bua tshinyi dienza dia endoscopie wa pa mutu (EGD) didi mua kuikala ne njiwu: Kubueja kapepe ka bukole ku diambuluisha dia gastroscope mu tshifu tshidi tshipanduluke kudi kuenza mudimu bu pompe wa dikalu, kuenzeja kapepe ne bactérie bua kupitshila mu tshitupa tshia munda tshia munda ne kukudimuna pneumothorax mupepele mu pneumothorax wa tension udi ushipa bantu. Endoscopie udi wenzeka anu mu nzubu wa dipanda ne dilongolola dia dipanda dia mutshima (kuenza mudimu ne \(\text{CO}_2\) wa luya lukese pamutu pa kapepe ka mu nzubu) padibu bateka stent wa endoscopie anyi tshiponji tshia vacuum.

Dipingaja dia muoyo mu lupitadi ne tshikondo tshia mêba 24 tshia dipanda ne tshia dilongolola dia endoscopie¶

1. Dilongolola dia lukasa dia malu a luondapu dia bitupa bisambombo mu tshibambalu tshia malu a mpukapuka¶

1. Mukenji wa NPO: Kakuena bualu nansha bumue ku mishiku mu nsombelu kayi yonso to.
2. Two Large-Bore Intravenous Lines & Crystalloid Resuscitation: Dibueja dia lukasa dia 0.9% normal saline anyi lactated Ringer's (30 mL/kg bolus bua sepsis/hypotension) ne diambuluisha dia kumpala dia norepinephrine dia vasopressor pikala septic shock .
3. High-Dose Intravenous Proton Pump Inhibitor (PPI): IV Pantoprazole anyi Esomeprazole (80 mg IV bolus, followed by 8 mg/hour continuous infusion or 40 mg IV every 12 hours) udi ukanga diakamue dipatuka dia aside wa hydrochloric wa mu tshifu bua pH yonso udi ushala mu tshifu udi upingana mu tshitupa tshia pH aside udi unyanguka.
4. Broad-Spectrum Intravenous Antibiotics AND Empiric Antifungal Therapy: Bidi ne tshia kuikala **aerobes ya mukana, anaérobes ya mukana, bacilli Gram-negatif ya mu tshifu, ne mishindu ya Candida (idi isomba mu tshifu ne lufu misangu ibidi mu mediastinitis):
5. Antibacterial: IV Piperacillin-Tazobactam (Zosyn) 4.5 g IV kunyima kua mêba 6 (anyi IV Meropenem 1 g IV kunyima kua mêba 8) PLUS IV Vancomycin (15 too ne ku 20 mg/kg IV kunyima kua mêba 8 too ne ku 12 bua MRSA).
6. Antifungal: IV Fluconazole (400 to 800 mg IV loading dose, then 400 mg dayly) or an Echinocandin (IV Micafungin 100 mg daily or Caspofungin), recommanded by **World Society of Emergency (WSES) transgery soal emural dibutuka.
7. Intraemetic antiemetic and Opioid Analgesia: IV Ondansetron (bua kuepula retching) ne titrated IV Fentanyl anyi Hydromorphone.
8. Tube Thoracostomy (Chest Tube Drainage): Diteka dia lukasa dia tube wa tshiadi tshia ku dia bakaji (28Fr too ne ku 32Fr) pikala hydropneumothorax wa ku dia bakaji anyi pleural effusion udi ufina mu mikolo.

2. Dilongolola dia tshimpitshimpi ne dia endoscopie bilondeshile dîba dia mêba 24¶

• Kasumbu A: Dileja dia kumpala (Dimanyibua mu mêba 24) Ne dibutuka dia mu tshiadi didi kadiyi dijika (Gold Standard Primary Surgical Repair):
• Munganga wa tshiadi udi wenza dipanda dia tshiadi dia ku dia bakaji (mu tshitupa tshia 6 anyi tshia 7 tshia pankatshi pa tshiadi) anyi dipanda dia tshiadi dia diambuluisha dia video (VATS).
• Dibue dia busanga dia mushinga mukole: Bu mudi dipanda dia munda mua mucosa dikale misangu yonso 1 too ne ku 3 santimetre mu bule kupita dipanda didi dimueneka mu tshitupa tshia pambelu tshia mubidi, munganga udi wenza myotomie wa mutantshi mule (udi ulengeja tshitupa tshia mubidi ku nseke yonso ibidi bua kuleja bule buonso bua mucosa), ne mucosa muscularis udi mukanga mu bitupa bibidi bishilangane bidi kabiyi ne lutatu, ne udi ukolesha (ukolesha) mulongo wa disonga ne tshitupa tshia mubidi tshidi ne mijilu, mafuta a mu tshifu, pleura, anyi fundus wa mu tshifu (tshitupa tshia Thal anyi tshia Dor) padiye uteka tu-tube tua mu tshiadi tua munkatshi ne tua mu pleura ne tube tua-tube jejuno (J).
• Kasumbu B: Endoscopic Self-Expanding Metal Stent (SEMS) anyi Endoluminal Vacuum Therapy (EndoVAC):
• Bua binsonji bikese (< 3 cm) bidibu bapeta kumpala kua dinyanguka dia tshiadi, anyi kudi babedi badi ne butekete bua bungi, baminganga ba endoscopiste badi batuma Stent wa tshiamu tshia mitaku (SEMS) udi mubuikila bimpe pa ditshibuka bua kukanga lumen (musangisha ne VATS anyi CT-guided chest tube drain), tshia mu tshiadi anyi tshia mu tshiadi anyi tshia munkatshi mua tshiadi Endoluminal Vacuum (EndoVAC) polyurethane sponge mulamakaja ku tshintu tshidi katshiyi tshienda tshikola ku \(-125\text{ mmHg}\) bua kupatula mâyi mu tshina ne kukoka mishiku ya tshifu tshikanga.
• Kasumbu C: Difila dia panyima pa dîba (Dimanyibua kunyima kua mêba 24 too ne ku 48) Ne mishiku ya lufu:
• Padibu bafika kunyima kua mêba 24 too ne ku 48, mielelu ya tshimanu tshia mu tshifu idi mivula, minyanguke ne mifue, bienza bua se: mionji ya kumpala ikoke bimpe mu misangu mitue ku 40 pa lukama. Baminganga badi benza dipanda dia tshitupa tshia munkatshi ne diumusha, pashishe dilongolola dikole pa tshiamu tshinene tshia T-tube (dienza dia fistula wa esophagocutaneous udibu bakokesha udi ukola mu mbingu), EndoVAC sponge therapy, anyi mu tshipupu tshikole tshia nekrose, dibutuka dia mu tshitupa tshijima tshia mubidi, diumusha/dibutuka dia mu tshiadi esophagostomy + gastrostomy) ne dilongolola dia tshiadi tshia muinshi mua tshiadi anyi dia tshifu tshia munda mua tshifu**.

Nomba ya tshimpitshimpi ya mu tshijengu ne mikenji ya bibambalu¶

• Etats-Unis ne Canada: Ela 911 diakamue bua disama dikole dia tshimpitshimpi dia mu tshiadi, dia mukolo, anyi dia ku mutu kua difu didi dilonda difu anyi difu. Lomba bua kuya ku lupitadi lua mushinga mukole ludi ne bukole bua Thoracic Surgery ne Interventional Gastroenterology, bilondeshile mikenji ya American Foregut Society (AFS) ne Society of Thoracic Surgeons (STS).
• Royaume-Uni: Ela 999 diakamue. Muinshi mua Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) ne NICE guidelines, disama dia Boerhaave didi dilomba dilengejibua dia lukasa, IV broad-spectrum antibiotics ne PPI, CT ne oral water-soluble contrast, ne dituma dia lukasa kudi munganga wa tshimpitshimpi Tshibambalu tshia dipanda dia tshifu**.
• Buobumue bua matunga a ku Mputu: Ela 112 mu matunga onso adi mu matunga a ku Mputu. Bibambalu bia ku Mputu bia diondopangana ne bia mu tshiadi bidi bilonda mikenji ya Société mondiale de surgery d’urgence (WSES) bua malu a tshimpitshimpi a mu tshifu, bishindika tshikondo tshia < 24-hour diagnostic ne dilongolola dia dipanda.
• Australie ne Nouvelle-Zélande: Ela 000 mu Australie anyi 111 mu Nouvelle-Zélande bua kuya ne diakamue ambulanse ku lupitadi lunene lua mu tshimenga tshinene ludi ne dipanda dia mutshima anyi dia tshiadi tshia kuulu.
• Asie-Pacifique: Ela 119 mu Japon ne mu Corée du Sud, 995 mu Singapour, 999 mu Malaysie ne mu Hong Kong, anyi 112 / 108 mu Inde bua kuya ku lupitadi lua tshimpitshimpi.

Nkonko itubu bela misangu ya bungi¶

Ndishilangana kayi didi pankatshi pa disama dia Mallory-Weiss ne disama dia Boerhaave kunyima kua dibutuka?¶

Malu onso abidi adi afumina ku dibutuka dia bukole anyi ku dibutuka, kadi adi mashilangane bikole mu buondoke ne mu njiwu. Disama dia Mallory-Weiss nditapa dia pa mutu didi kadiyi dikola mu tshitupa tshia munda tshia mucose muaba udi tshintu tshia kudia tshisambakena ne tshifu; bidi bifikisha ku diela mashi makunze kakuyi kanyinganyinga kakole ka mu tshiadi, ne 90 pa lukama badi buondopa nkayabu ne manga adi akanda aside. Disama dia Boerhaave i disama dia tshipupu tshikole tshidi tshipita mu bitupa bionso bia tshimanu tshia misunya ya mu tshiadi; udi ukebesha disama dia tshimpitshimpi, dia kanyinganyinga 10 pa 10 dia mu tshiadi anyi dia mu tshifu tshia kuulu, dipanga dia mupuya, ne bipupu bia kapepe muinshi mua dikoba dia mu nshingu, ne misangu ya bungi bitu ne mashi makese menemene mu tshifu bualu mâyi adi apueka pambelu pa tshifu mu tshiadi. Disama dia Boerhaave i disama dia tshimpitshimpi didi mua kunyanga muoyo.

Bua tshinyi mbikandike bikole bua kunua nansha dikopo dimue dia mâyi padibu bela meji ne: udi ne disama dia Boerhaave?¶

Padi muntu ne disama dia Boerhaave, kudi tshina tshia 2 too ne ku 6 tshia santimetre tshidi tshipatuka mu tshimanu tshia tshibombi tshia biakudia tshia kuinshi (tshia tshiadi) munda mua tshiadi tshiende. Ditompa dionso dia mayi, dia antacide, anyi tshiamu tshia mashika tshidi muntu umina tshidi tshipatuka buludiludi mu tshina atshi mu muaba udi kauyi ne tshintu tshidi tshinyunguluke mutshima (mediastinum) ne tshiadi tshia ku dia bakaji, tshisukula miliyo ya bactérie ya mukana mu tshina tshia tshiadi ne tshivudija disama dia mediastinite didi mua kushipa bantu. Kulama mubedi 100 pa lukama NPO (kakuyi tshintu ku mishiku) padibu bamupesha mâyi a mu mishipa ne bintu bidi bipangisha aside ku mushipa kudi ne mushinga.

Mackler's triad ntshinyi, ne muntu yense udi ne tshifu tshitapuluke udi ne bimanyinu bionso bisatu anyi?¶

Mackler's triad i mukanda wa kale udi uleja bimanyinu bisatu bia dinyanguka dia tshifu: (1) Dibutuka dia bukole anyi dibutuka; (2) Disama dia tshimpitshimpi, dikole dia muinshi mua tshiadi anyi dia kuulu kua difu; ne (3) Disama dia muinshi mua dikoba mu nshingu (tupese tukese tua kapepe tudi muinshi mua dikoba pa mutu pa mifuba ya nshingu tudi tuenza bu Rice Krispies anyi Bubble Wrap padibu bawulenga). Ino, makebulula a munganga adi aleja ne: bimanyinu bionso bisatu ebi bidi pamue mu bantu batue ku tshitupa tshia babedi mu mêba makese a kumpala bualu bidi bilomba mêba a bungi bua kapepe kupatuka mu tshiadi kuya mu dikoba dia mu nshingu. Kulekedi disama dia Boerhaave anu bualu bua se: bipupu bia mu nshingu kabitu bianji kumueneka to.

Bua tshinyi 90 pa lukama ya dinyanguka dia tshifu didi dienzeka ku dia bakaji dia panyima pa tshifu?¶

Tshimanu tshia ku dia bakaji tshia tshiadi tshia kuinshi tshia tshifu (pabuipi ne santimetre 2 anyi 4 pa mutu pa diaphragme) ntshitupa tshia mubidi tshidi tshitekete menemene tshia mu tshibombi tshijima tshia biakudia bua malu anayi: tshitupa tshia mubidi tshidi tshienda tshikepela ne tshienda tshikepela kuntu aku, mijilu ne mishipa ya mashi bidi bibueja tusoso tukese mu tshimanu tshia mifuba muaba au, tshifu tshidi tshiangata tshifu tshia kumpala ne tshia kumpala kukudimuka bua kupitshila mu diaphragme, ne bishilangane ne luseke lua dia balume (ludi lushindamene pa mukolo ne aorte), tshimanu tshia ku dia bakaji tshidi tshilengeja kakuyi tshintu tshidi tshikuatshisha anu ku luseke lua tshibombi tshikese tshia ku dia bakaji. Padi bukole bua tshisuku bufika ku 200 mmHg ku nshingu mukanga, tshimanu tshia kuinshi tshia ku dia bakaji tshidi tshipatuka.

Bua tshinyi baminganga batu benza mudimu ne tshiamu tshia nzembu tshidi mua kunyanguka mu mayi (Gastrografin) pamutu pa tshiamu tshia barium tshia pa tshibidilu bua kuenza natshi X-ray anyi CT scan?¶

Munganga yeye mupeshe mubedi udi ne tshina mu tshiadi tshiende barium wa mâyi makole, barium udi upatuka mu tshina etshi ne uya mu tshina tshia mu tshiadi tshidi tshinyunguluke mutshima ne mapapa. Bu mudi mubidi wa muntu kauyi mua kusunguluja anyi kuangata sulfate wa barium, barium udi mukuatshike mu tshiadi udi ukebesha disama dikole dia kashidi dia mubidi wa bende ne mputa (granulomatous mediastinitis). Pamutu pa nanku, baminganga badi banji kuenza mudimu ne dikala dia iode didi dinyanguka mu mayi (bu mudi Gastrografin anyi Omnipaque), didi dileja patoke dipatuka dia mâyi ku tshiamu tshia CT anyi tshia X-ray ne didi dibuela mu mubidi kakuyi bualu bubi. Anu pikala tshikebelu tshia mu mayi tshikale tshibi ne baminganga batshidi anu bela meji ne: kudi tshitupa tshikese tshia nsuki ke padibu mua kunua kabidi ne barium mukese.

Hamman's crunch (tshimanyinu tshia Hamman) ntshinyi?¶

Tshimanyishilu tshia Hamman (anyi Hamman's mediastinal crunch) i mutoyi wa pa buawu wa dikuma, wa dikuma, wa dikuma, anyi wa dibutuka udi umvuika munkatshi mua tshiadi udi ukuma mu tshikondo tshijalame ne dikuma dia mubedi pamutu pa mupuya wende. Bidi bienzeka padi kapepe kapatuka mu tshifu tshidi tshipanduluke mu tshitupa tshidi tshinyunguluke tshibombi tshia mutshima (pneumomediastinum), nunku dîba dionso didi mutshima udikosa, udi ufina bipese bia kapepe ku tshimanu tshia tshiadi.

Miaba ne buludiki bua mbulamatadi¶

• World Society of Emergency Surgery (WSES): Esophageal Emergency: WSES Guidelines for the Diagnosis and Management of Boerhaave Syndrome and Traumatic Esophageal Perforations (24-hour surgical window, CT esophagogram, antibacterial and antifungal coverage and two-payer vs two-payer vs SEMS. EndoVAC).
• Society of Thoracic Surgeons (STS) and American Foregut Society (AFS, United States): Clinical Consensus on Barogenic Esophageal Rupture (Syndrome de Boerhaave): Thoracotomy, VATS Decortication, Buttressed Myotomy Repair, and Hybrid Endoscopic Stenting.
• Tshisumbu tshia baminganga ba mu tshifu tshia kuulu tshia mu Grande-Bretagne ne mu Irlande (AUGIS) ne Société britannique wa baminganga ba mu tshifu (BSG): Mibelu ya mu UK idi itangila dilama dia dibutuka dia tshifu ne ditshibuka dia mpukapuka.
• American College of Radiology (ACR): ACR Appropriateness Criteria for Suspected Esophageal Perforation: Water-Soluble Contrast Esophagography and CT Esophagogram Protocol.
• European Society of Gastrointestinal Endoscopy (ESGE): Position Statement on Endoscopic Stenting and Endoluminal Vacuum Therapy (EndoVAC) for Gastrointestinal and Esophageal Leaks.

Malu adi apetangana¶

• Dipatuka dia mashi mu tshifu, dipatuka dia mashi (hematemesis), ne melena
• Ditapa dia mashi a mu tshifu, dipatuka dia mashi mu tshifu, ne disama dia tshiadi
• Dikosolola dia aorte ne ditapa dia aneurysme wa aorte wa mu difu
• Dimanya dia sepsis ne dia septic shock ne diambuluisha dia lukasa
• Nomba ya njiwu bilondeshile ditunga