Gastroenterology · Esophageal Disorders
The facts most likely to be tested
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.
Contrast esophagography using water-soluble contrast (e.g., Gastrografin) is the diagnostic test of choice to confirm the leak.
Barium swallow is contraindicated as the initial diagnostic test because it causes mediastinitis if it leaks into the pleural space.
Surgical consultation for emergent esophageal repair is the definitive management for patients with hemodynamic instability or significant mediastinal contamination.
Vignette unlocked
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. 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?
Water-soluble contrast esophagography
The patient presents with the classic signs of Boerhaave syndrome (Mackler triad and Hamman sign); water-soluble contrast is required to confirm the transmural rupture while avoiding the inflammatory risks of barium.
Full handout
High yield triage
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
Contrast esophagography with water-soluble contrast is the gold standard for diagnosis.
Treatment
Requires emergent surgical consultation and broad-spectrum antibiotics; avoid barium.
Prognosis
High mortality if untreated; >90% mortality if surgical intervention is delayed beyond 24 hours.
Full handout
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
The gold standard is contrast esophagography using water-soluble contrast (e.g., Gastrografin) to visualize the leak. If the initial study is negative but clinical suspicion remains high, a CT scan of the chest with oral contrast is indicated. Barium is strictly contraindicated due to the risk of severe mediastinitis.
Treatment
Management requires NPO status, IV fluids, and broad-spectrum antibiotics covering oral flora. Emergent surgical consultation is mandatory for primary repair or drainage. Do not perform endoscopy as the insufflation can worsen the mediastinal contamination.
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