- Clinical science
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. Diagnosis of esophageal perforation is confirmed via neck or chest x-ray, esophagram, and/or CT of the neck and chest. 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).
- Boerhaave syndrome: ♂ > ♀ (3:1)
Epidemiological data refers to the US, unless otherwise specified.
Esophageal perforation (general) 
Iatrogenic esophageal perforation: most common cause of esophageal perforation
- Most often injury during upper endoscopy
- Injury related to surgery
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
- Neck, retrosternal chest, and/or epigastric pain with radiation to the back
- 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
Approach: : If esophageal perforation or Boerhaave syndrome is suspected, a neck or a chest x-ray is first conducted; . If inconclusive, an esophagram and/or CT scan is conducted to confirm the diagnosis 
- Initial diagnostic study
Confirmatory test that reveals location and size of rupture
- Contrast esophagography (gold standard): Contrast leak 
- If the patient is unstable/uncooperative, pneumoperitoneum is detected on x-ray, or x-rays and contrast esophagography are inconclusive
If CT scan is inconclusive
- Consider flexible endoscopy: should be reserved for patients with a poorly localized esophageal perforation and those with a therapeutic indication for endoscopy.
- See .
The differential diagnoses listed here are not exhaustive.
Initial approach 
- ABCDE survey
- Establish airway and/or provide supplemental oxygen as needed.
- IV fluid resuscitation
- Nothing by mouth (NPO) and supply nutritional support
- Broad-spectrum IV antibiotics (see )
- IV proton pump inhibitor (e.g., pantoprazole )
- Parenteral analgesics (see acute pain management)
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
- Esophageal stent placement
- Fibrin glue application
Surgical treatment 
- Hemodynamic instability
- Patients who do not fulfill the criteria for conservative management
- Clinical deterioration during conservative management
- Closure of the ruptured esophageal segment
- Last resort: esophagectomy
- Supplemental oxygen as needed
- IV fluid resuscitation
- Empiric broad-spectrum intravenous antibiotics
- Immediate thoracic surgery and GI consults for consideration of endoscopic vs. surgical management
- Consider nasogastric tube insertion after discussion with surgical consult.
- Parenteral analgesics: See acute pain management.
- Intravenous proton pump inhibitor
- Chest tube placement if pneumothorax or pleural effusion is present
- ICU transfer and close monitoring
- Clinical features
- Diagnosis: Chest x-ray (posteroanterior and lateral views) shows a widened mediastinum and mediastinal emphysema.
- Management: resuscitation, IV antibiotic therapy, and surgical debridement
We list the most important complications. The selection is not exhaustive.
- Mortality: 10–50%