Gastroenterology · Esophageal Disorders
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Boerhaave syndrome is a transmural esophageal rupture typically caused by forceful retching or vomiting.
The classic clinical presentation is Mackler triad, consisting of vomiting, chest pain, and subcutaneous emphysema.
Physical examination often reveals Hamman sign, a crunching or clicking sound heard on auscultation that is synchronous with the heartbeat.
The rupture most commonly occurs in the distal esophagus on the left posterolateral wall.
CT esophagography (chest CT with water-soluble oral contrast, usually with IV contrast) is the preferred initial imaging in stable patients per WSES (2019); water-soluble contrast esophagography remains a useful confirmatory study when CT is equivocal.
Barium is generally avoided as the initial contrast agent because extravasated barium can worsen mediastinitis; water-soluble contrast is used first.
Surgical consultation for emergent esophageal repair is the definitive management for patients with hemodynamic instability or significant mediastinal contamination.
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A 55-year-old male presents to the emergency department with severe, sudden-onset retrosternal chest pain that began after a heavy meal and subsequent episodes of forceful vomiting. On physical exam, the patient is diaphoretic and tachycardic (heart rate 112/min) with a blood pressure of 128/80 mm Hg. Auscultation of the heart reveals a crunching sound synchronous with the heartbeat. Palpation of the neck and upper chest reveals crepitus.
What is the most appropriate next step in the diagnostic evaluation of this patient?
CT of the chest with water-soluble oral contrast (CT esophagography)
Forceful vomiting followed by retrosternal chest pain, subcutaneous emphysema, and Hamman sign suggest Boerhaave syndrome. In a hemodynamically stable patient, CT esophagography (chest CT with water-soluble oral contrast, usually with IV contrast) is the preferred initial study per WSES (2019, Grade 1C): it is fast and sensitive, and it shows mediastinal air, fluid collections, and alternative diagnoses such as aortic dissection. Water-soluble contrast esophagography remains a useful confirmatory study when CT is equivocal; barium is generally avoided initially because extravasation can worsen mediastinitis.
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Etiology / Epidemiology
Caused by forceful emesis or straining; most common in middle-aged males with history of alcohol abuse.
Clinical Manifestations
Presents with Mackler triad: vomiting, chest pain, and subcutaneous emphysema.
Diagnosis
CT esophagography (CT with water-soluble oral contrast) is the preferred initial imaging per WSES (2019); water-soluble contrast esophagography is a confirmatory option.
Treatment
Warrants emergent surgical consultation and broad-spectrum antibiotics; avoid barium.
Prognosis
High mortality if untreated (>90%); mortality is roughly 50-65% if surgical intervention is delayed beyond 24 hours and approaches 90% beyond 48 hours.
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Epidemiology & Etiology
Occurs most frequently in males aged 40-60 years. Primary etiology is barogenic esophageal rupture following intense episodes of vomiting, retching, or Valsalva maneuvers. Often associated with bulimia nervosa or heavy alcohol consumption.
Pertinent Anatomy
The rupture typically occurs in the distal esophagus along the left posterolateral wall. This location is anatomically vulnerable due to the lack of supportive surrounding structures.
Pathophysiology
Increased intragastric pressure against a closed glottis leads to a full-thickness tear of the esophageal wall. This allows gastric contents and air to enter the mediastinum, triggering severe inflammation and chemical mediastinitis. If left unchecked, this progresses rapidly to sepsis and multi-organ failure.
Clinical Manifestations
Patients present with sudden, severe retrosternal chest pain radiating to the back. Physical exam may reveal Hamman's sign (mediastinal crunch on auscultation). Subcutaneous emphysema in the neck or supraclavicular region is a critical, late-stage finding.
Diagnosis
CT esophagography (chest CT with water-soluble oral contrast, usually with IV contrast) is the imaging examination of choice per WSES (2019, Grade 1C) because it is fast, sensitive, and also shows pneumomediastinum, fluid collections, and alternative diagnoses. Water-soluble contrast esophagography (e.g., Gastrografin) is useful in select cases to localize the leak or when CT is equivocal, and some references (e.g., StatPearls) still list it first; endoscopy is an adjunct when CT findings are doubtful. Barium is generally avoided as the initial agent because extravasation can worsen mediastinitis.
Treatment
Management includes NPO status, IV fluids, and broad-spectrum antibiotics covering oral flora. Emergent surgical consultation is indicated for primary repair or drainage. Flexible endoscopy is used cautiously in some centers; CT chest with oral contrast and water-soluble esophagography are preferred to confirm the leak.
Prognosis
Prognosis is time-dependent; survival drops significantly if treatment is delayed beyond 24 hours. Mediastinitis and sepsis are the primary causes of mortality.
Differential Diagnosis
Mallory-Weiss tear: mucosal tear only, usually presents with hematemesis
Myocardial infarction: ECG changes and cardiac enzymes, no subcutaneous emphysema
Aortic dissection: tearing chest pain radiating to the back, widened mediastinum on CXR
Pneumothorax: absent breath sounds, hyperresonance to percussion
Peptic ulcer perforation: free air under the diaphragm, abdominal rigidity