- Clinical science
Boerhaave syndrome is the transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure. The condition is associated with recent excessive consumption of alcohol or food, repeated episodes of vomiting, and other causes of elevated intrathoracic pressure (e.g., childbirth, seizure, prolonged coughing). The classic complaint is severe retrosternal pain, which is due to the development of mediastinal emphysema after massive emesis. However, a third of patients with Boerhaave syndrome present atypically. Diagnosis is confirmed via chest x-ray, esophagram and/or CT. Surgical repair of the esophageal rupture is often essential, although conservative treatment alone may be considered in select cases (e.g., if the perforation is very small and the patients is stable).
- Age range: 50–70 years (but may present in any age group)
- Sex: ♂ > ♀ (3:1)
Epidemiological data refers to the US, unless otherwise specified.
- Severe vomiting/increased intrathoracic pressure → rupture of all layers of the esophageal wall
- In > 90% of cases, the rupture occurs in the distal third of the esophagus on the left dorsolateral wall surface.
- Affected individuals typically do not have preexisting esophageal abnormalities.
- Triad of (the Mackler triad):
- Dyspnea, cyanosis
- Atypical symptoms: very mild or absent thoracic pain; no history of vomiting
Always ask about vomiting if a patient presents with thoracic pain! Approximately one‑third of patients present with atypical symptoms!
If Boerhaave syndrome is suspected, a chest x-ray is first conducted. If inconclusive, an esophagram and/or CT scan is conducted to confirm the diagnosis
- Chest x-ray findings
- Contrast esophagram with gastrografin: : a confirmatory test that reveals location and size of rupture
- CT scan: indicated in unstable/uncooperative patients, pneumoperitoneum on x-ray, or if x-rays and contrast esophagram are inconclusive
- If imaging is inconclusive: endoscopy
- Pleural tap
Other causes of esophageal rupture
Iatrogenic esophageal perforation: most common cause of esophageal perforation
- Generally injury during upper endoscopy
- Symptoms usually within 24 hours of endoscopy
- Foreign body ingestion
- Malignancy 
- Iatrogenic esophageal perforation: most common cause of esophageal perforation
- Presentation: see clinical features above
- For initial diagnostic workup, see “Diagnostics” above
- See “Treatment” below
- Treat the underlying cause
The differential diagnoses listed here are not exhaustive.
- Small, contained perforation, demonstrated by:
- The perforation site is benign, outside of the abdomen, and distal to an obstruction
- Stable medical condition without evidence of
- Contrast studies can be performed at any time of day
- A skilled thoracic surgeon must always be available
- Clinical deterioration during conservative management
- Patients who do not fulfill the criteria for conservative management
- Surgical repair and closure of the ruptured esophageal segment
- Last resort: esophagectomy
- Retrosternal and/or back pain
- Subcutaneous emphysema in the neck and face
- Fever, tachycardia, tachypnea
- Bacteremia leading to sepsis and signs of shock
- Obstruction of the upper airways
- May further develop into pleuritis and pericarditis
- Thrombosis of the vena cava; mediastinal fibrosis (chronic mediastinitis)
- Diagnosis: chest x-ray (posteroanterior and lateral views) shows a widened mediastinum and mediastinal emphysema
- Management: adequate resuscitation, IV antibiotic therapy, and surgical debridement
We list the most important complications. The selection is not exhaustive.
Boerhaave, a Dutch physician in the 18th century, described this illness after a friend vomited and collapsed to his death following an extravagant meal they had eaten together. The autopsy, performed by Boerhaave, demonstrated esophageal rupture as the cause of death.