Perforation of the esophagus is most commonly caused by upper endoscopy (iatrogenic), foreign body ingestion, or trauma. It can be located at any point along the esophagus, in the cervical, thoracic, or abdominal region. Boerhaave syndrome is a spontaneous subtype of esophageal perforation characterized by transmural rupture of the esophagus following an episode of forceful vomiting/retching or increased intrathoracic pressure. The condition is associated with recent consumption of large amounts of alcohol or food, repeated episodes of vomiting, and other causes of elevated intrathoracic pressure (e.g., childbirth, seizure, prolonged coughing). The classic symptom is severe retrosternal pain, which is due to the development of mediastinal emphysema after massive emesis. Evidence of esophageal perforation may be seen on neck, chest, and/or abdominal x-ray and the diagnosis is confirmed with esophagram and/or CT esophagography. Surgical repair of the esophageal rupture is often necessary, although conservative treatment alone may be considered in select cases (e.g., if the perforation is very small and the patient is stable).
Esophageal perforation (general) 
- Iatrogenic esophageal perforation
Ingestion of a foreign body or caustic material
- Bone, dentures
- Alkali or acidic agents (e.g., batteries)
- Trauma (blunt or penetrating)
- Spontaneous rupture
- Risk factors
- Mackler triad (esp. in Boerhaave syndrome)
- Dyspnea, tachypnea, tachycardia
- Signs of sepsis
- History of recent endoscopy: Symptoms usually occur within 24 hours of endoscopy.
- Delayed presentations: critically ill with sepsis and multiorgan dysfunction
In suspected esophageal perforation or Boerhaave syndrome, x-ray of the chest, abdomen, and/or neck is first conducted, followed by contrast esophagography. If inconclusive, or the patient is unstable or unable to cooperate, a CT scan is conducted to confirm the diagnosis. 
Initial diagnostic studies
- Chest x-ray posteroanterior and lateral, upright AXR
- Neck x-ray lateral : subcutaneous emphysema
As radiographic abnormalities may not be immediately apparent after injury, negative results on early plain x-rays do not rule out acute perforation. 
- Contrast esophagography (gold standard): Contrast leak reveals the location and size of the rupture. 
CT chest and CT esophagography (with oral contrast) 
Flexible endoscopy: direct visualization of the perforation 
- Typically reserved for patients with penetrating external esophageal injury
- Avoided in nonpenetrating injury unless there is a specific therapeutic indication
The differential diagnoses listed here are not exhaustive.
Initial management 
- ABCDE survey
- Nothing by mouth (NPO) 
- IV proton pump inhibitor (e.g., pantoprazole )
- Broad-spectrum IV antibiotics: Initiate early in all patients.
- Chest tube placement: Consider for pneumothorax or pleural effusions.
- and as needed
- Urgent thoracic surgery and GI consult
Patients with esophageal perforation can deteriorate rapidly and benefit from close monitoring in the ICU and early surgical consultation. 
Nonsurgical treatment 
- Small, contained perforation, demonstrated by:
- The perforation site is benign, outside of the abdomen, and distal to an obstruction.
- The patient is stable with no evidence of sepsis.
- Contrast studies are available at any time for follow-up evaluation.
- A skilled thoracic surgeon is continuously available.
- Consider endoscopic intervention
Surgical treatment 
- Airway management and supplemental oxygen as needed
- IV fluid resuscitation
- Empiric broad-spectrum IV antibiotics
- Immediate thoracic surgery and GI consults for consideration of endoscopic vs. surgical management
- Consider nasogastric tube insertion only after discussion with surgical consult.
- Parenteral analgesics and antiemetics
- Intravenous proton pump inhibitor
- Chest tube placement if pneumothorax or pleural effusion is present
- ICU transfer and close monitoring
- Definition: inflammation of the tissues in the mediastinum
- Classification 
- Acute mediastinitis
- Etiology remains unclear.
- Several studies report that Histoplasma capsulatum is causative.
- Clinical features
- Chest x-ray (posteroanterior and lateral views) shows a widened mediastinum and mediastinal emphysema.
- CT neck and chest (confirmatory test) shows attenuation of mediastinal fat, as well as mediastinal fluid collections and gas. 
- CBC may show leukocytosis.
- Blood, tissue, and/or fluid (mediastinal, pleural, or bronchoalveolar) cultures can help determine the causative organism.
- Resuscitation using the ABCDE approach
- Broad spectrum IV antibiotics depending on the underlying etiology; see: 
- Urgent surgical consultation for debridement and drainage 
- Disposition: Patients often require ICU admission.
We list the most important complications. The selection is not exhaustive.
- Mortality: 10–50%