Boerhaave Syndrome (Esophageal Perforation)

Risk factors

• Forceful or recurrent vomiting (alcohol binge, eating disorder, gastroenteritis)
• Predisposing esophageal disease: eosinophilic esophagitis, peptic stricture, Barrett, malignancy
• Iatrogenic: dilation, EGD with biopsy, TEE, NG/OG tube placement
• Trauma, caustic ingestion, foreign body, pill esophagitis

Pathophysiology

A sudden rise in intraluminal pressure exceeds esophageal wall tensile strength, producing a longitudinal full-thickness tear, most often in the left posterolateral distal esophagus where the wall is thinnest. Gastric contents enter the mediastinum and pleural space, producing chemical and then bacterial mediastinitis, pleural effusion, empyema, and sepsis.

Clinical presentation

Differential diagnosis

• Acute coronary syndrome — Substernal pressure with diaphoresis, ECG changes, troponin elevation; no vomiting trigger
• Aortic dissection — Tearing chest/back pain, BP differential, widened mediastinum; CTA diagnostic
• Pulmonary embolism — Pleuritic pain, hypoxia, tachycardia; CTPA diagnostic
• Pneumothorax / tension pneumothorax — Unilateral absent breath sounds, hyperresonance, tracheal deviation
• Mallory-Weiss tear — Mucosal only; hematemesis without perforation signs; no pneumomediastinum
• Perforated peptic ulcer — Sudden epigastric pain with rigid abdomen, free air under diaphragm
• Pancreatitis — Epigastric pain radiating to back, elevated lipase; may coexist with esophageal injury after vomiting

Diagnostic workup

Diagnostic algorithm

flowchart TD
  A[Severe chest pain<br/>after forceful vomiting] --> B[Upright CXR + IV access<br/>broad-spectrum antibiotics, PPI]
  B --> C{Pneumomediastinum,<br/>SQ emphysema, or<br/>L pleural effusion?}
  C -->|Yes| D[CT chest with water-soluble<br/>oral contrast]
  C -->|No but high suspicion| D
  D --> E{Perforation confirmed?}
  E -->|Yes| F[Surgical consult emergently]
  F --> G{<24 h, stable,<br/>contained?}
  G -->|Yes| H[Primary repair<br/>+ drainage]
  G -->|No / delayed / unstable| I[Stent, esophageal diversion,<br/>or esophagectomy]
  E -->|No / equivocal| J[Esophagram<br/>Gastrografin then barium]

Treatment

Complications

• Mediastinitis, empyema, pleural effusion
• Septic shock and multiorgan failure
• Esophageal stricture or fistula (esophagopleural, esophagobronchial)
• ARDS
• Death (mortality 20-50% depending on time to diagnosis)

PANCE pearls

• Time is esophagus — mortality doubles after 24 h delay.
• Mackler triad is classic but only present in a minority; do not exclude Boerhaave by its absence.
• Always get an upright CXR in any patient with severe chest pain after vomiting — pneumomediastinum is the giveaway.
• Use water-soluble (Gastrografin) contrast first; barium gives better detail but is more inflammatory if it extravasates.
• Iatrogenic perforation (most commonly cervical from EGD) is the most common cause of esophageal perforation overall; Boerhaave is spontaneous and usually distal.

References

• WSES 2019 — World Society of Emergency Surgery (WSES) guidelines for the management of esophageal perforations (Chirica et al., World J Emerg Surg 2019)
• SAGES 2014 — SAGES guidelines for the diagnosis and treatment of esophageal perforation