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Emergency and Acute Medicine – Boerhaave Syndrome
Overview and Definitions
Boerhaave syndrome refers to a spontaneous rupture of the esophagus caused by a sudden rise in intra-abdominal pressure combined with negative intrathoracic pressure. This results in a full-thickness, transmural longitudinal tear. The absence of a serosal layer in the esophagus makes it particularly vulnerable to perforation and rapid mediastinal contamination. Preexisting mucosal injury, such as esophagitis, further weakens the wall. Most ruptures occur along the left posterolateral aspect of the distal third of the esophagus. This condition carries very high morbidity and mortality, the highest among gastrointestinal perforations. Overall mortality approaches 20%, and delays beyond 24 hours may double mortality. Cervical perforations have the lowest mortality, followed by abdominal and thoracic ruptures.
Etiology
The most frequent precipitant is forceful vomiting or retching. Other associated triggers include heavy lifting, seizures, childbirth, blunt trauma, induced emesis, caustic ingestion, and laughing. Risk is increased in patients with Barrett ulcer, HIV/AIDS, pill esophagitis, and chronic alcohol use. The condition predominantly affects middle-aged men. Notably, iatrogenic causes account for over half of all esophageal perforations overall.
Pediatric note: Rare; reported in neonates. Always consider caustic ingestion.
Clinical Features
Symptoms are often nonspecific, contributing to diagnostic delay. The most common presentation is acute chest or epigastric pain following vomiting or retching.
Mackler triad—vomiting, chest pain, and subcutaneous emphysema—is classic but uncommon. Chest pain is typically retrosternal and pleuritic, radiates to the back or left shoulder, worsens with swallowing, and may be associated with odynophagia. Swallowing can provoke coughing. A history of heavy alcohol intake is frequently present.
Alert: Subtle or vague symptoms are common and worsen prognosis if diagnosis is delayed.
Physical Examination
Findings may include dyspnea, diaphoresis, tachypnea, fever, and shock in severe cases. Subcutaneous emphysema of the neck or chest wall and mediastinal crepitus (Hamman crunch) may be present. Pleural effusions, usually left-sided, are common. Untreated cases progress to mediastinitis and abscess formation. Hemorrhage is uncommon.
Essential Evaluation
Obtain upright chest radiographs (PA and lateral if tolerated) to assess for pneumomediastinum, subcutaneous emphysema, pleural effusion, pneumothorax, widened mediastinum, hydropneumothorax, empyema, free intraperitoneal air, and the Naclerio V sign.
A contrast esophagram is key to identifying the perforation and guiding management. Contrast choice remains debated: water-soluble agents are less irritating if leaked but less sensitive and dangerous if aspirated, while barium is more sensitive but more irritating to the mediastinum. If the initial study is negative and suspicion remains high, repeat imaging is warranted.
Diagnostic Tests and Interpretation
Laboratory studies include CBC, PT/PTT/INR, and blood cultures. Pleural fluid analysis may show low pH (<6), elevated amylase, and undigested food particles. ecg is useful to exclude cardiac causes.< />pan>
CT chest is sensitive for detecting mediastinal air, periesophageal fluid, and pleural involvement, though it does not localize the tear. Endoscopy is controversial due to risk of worsening the perforation.
Differential Diagnosis
Myocardial infarction, aortic dissection, pneumothorax, pneumonia, pulmonary embolism, pericarditis, pancreatitis, cholecystitis, intestinal obstruction, mesenteric ischemia, lung abscess, ruptured viscus, and benign spontaneous pneumomediastinum.
Management
Prehospital: Secure the airway if needed. Establish two large-bore IV lines and treat hypotension with 0.9% normal saline. Avoid opiates prior to ED arrival when possible.
Initial stabilization: Follow ABCs. Administer 100% oxygen or intubate if airway compromise is present. Give 20 mL/kg crystalloid bolus and initiate dopamine if hypotension persists. Consider central access for unstable patients.
ED care: Keep patient NPO, carefully place a nasogastric tube for decompression, insert a urinary catheter, expedite diagnostic evaluation, and obtain immediate surgical consultation. Definitive treatment is usually surgical repair; endoscopic stenting or conservative management may be considered in selected patients with contained perforations. Begin broad-spectrum IV antibiotics targeting oral and gastrointestinal flora.
Medications
Ampicillin/sulbactam 3 g IV q6h; Gentamicin 2 mg/kg loading dose then 1.7 mg/kg q8h or 5–7 mg/kg daily; Imipenem/cilastatin 250–500 mg IV q6h; Dopamine 2–20 μg/kg/min IV as needed.
Disposition
All patients require admission to a surgical ICU. Cervical perforations may be managed with drainage alone, whereas thoracic and abdominal perforations require operative repair. There is no role for ED discharge.
Consultation and Follow-Up
Immediate involvement of thoracic or general surgery is mandatory. Ongoing management and follow-up are dictated by the surgical team.
Key Clinical Insights And Common Errors
Early chest radiographs may appear normal. Left-sided pleural involvement typically indicates distal esophageal rupture, whereas right-sided involvement suggests a proximal tear. A negative initial esophagram does not exclude injury—repeat imaging in decubitus positions if suspicion remains high. Delays in diagnosis and intervention markedly increase mortality; rapid recognition and early surgical consultation are essential.
Overview and Definitions
Boerhaave syndrome refers to a spontaneous rupture of the esophagus caused by a sudden rise in intra-abdominal pressure combined with negative intrathoracic pressure. This results in a full-thickness, transmural longitudinal tear. The absence of a serosal layer in the esophagus makes it particularly vulnerable to perforation and rapid mediastinal contamination. Preexisting mucosal injury, such as esophagitis, further weakens the wall. Most ruptures occur along the left posterolateral aspect of the distal third of the esophagus. This condition carries very high morbidity and mortality, the highest among gastrointestinal perforations. Overall mortality approaches 20%, and delays beyond 24 hours may double mortality. Cervical perforations have the lowest mortality, followed by abdominal and thoracic ruptures.
Etiology
The most frequent precipitant is forceful vomiting or retching. Other associated triggers include heavy lifting, seizures, childbirth, blunt trauma, induced emesis, caustic ingestion, and laughing. Risk is increased in patients with Barrett ulcer, HIV/AIDS, pill esophagitis, and chronic alcohol use. The condition predominantly affects middle-aged men. Notably, iatrogenic causes account for over half of all esophageal perforations overall.
Pediatric note: Rare; reported in neonates. Always consider caustic ingestion.
Clinical Features
Symptoms are often nonspecific, contributing to diagnostic delay. The most common presentation is acute chest or epigastric pain following vomiting or retching.
Mackler triad—vomiting, chest pain, and subcutaneous emphysema—is classic but uncommon. Chest pain is typically retrosternal and pleuritic, radiates to the back or left shoulder, worsens with swallowing, and may be associated with odynophagia. Swallowing can provoke coughing. A history of heavy alcohol intake is frequently present.
Alert: Subtle or vague symptoms are common and worsen prognosis if diagnosis is delayed.
Physical Examination
Findings may include dyspnea, diaphoresis, tachypnea, fever, and shock in severe cases. Subcutaneous emphysema of the neck or chest wall and mediastinal crepitus (Hamman crunch) may be present. Pleural effusions, usually left-sided, are common. Untreated cases progress to mediastinitis and abscess formation. Hemorrhage is uncommon.
Essential Evaluation
Obtain upright chest radiographs (PA and lateral if tolerated) to assess for pneumomediastinum, subcutaneous emphysema, pleural effusion, pneumothorax, widened mediastinum, hydropneumothorax, empyema, free intraperitoneal air, and the Naclerio V sign.
A contrast esophagram is key to identifying the perforation and guiding management. Contrast choice remains debated: water-soluble agents are less irritating if leaked but less sensitive and dangerous if aspirated, while barium is more sensitive but more irritating to the mediastinum. If the initial study is negative and suspicion remains high, repeat imaging is warranted.
Diagnostic Tests and Interpretation
Laboratory studies include CBC, PT/PTT/INR, and blood cultures. Pleural fluid analysis may show low pH (<6), elevated amylase, and undigested food particles. ecg is useful to exclude cardiac causes.< />pan>
CT chest is sensitive for detecting mediastinal air, periesophageal fluid, and pleural involvement, though it does not localize the tear. Endoscopy is controversial due to risk of worsening the perforation.
Differential Diagnosis
Myocardial infarction, aortic dissection, pneumothorax, pneumonia, pulmonary embolism, pericarditis, pancreatitis, cholecystitis, intestinal obstruction, mesenteric ischemia, lung abscess, ruptured viscus, and benign spontaneous pneumomediastinum.
Management
Prehospital: Secure the airway if needed. Establish two large-bore IV lines and treat hypotension with 0.9% normal saline. Avoid opiates prior to ED arrival when possible.
Initial stabilization: Follow ABCs. Administer 100% oxygen or intubate if airway compromise is present. Give 20 mL/kg crystalloid bolus and initiate dopamine if hypotension persists. Consider central access for unstable patients.
ED care: Keep patient NPO, carefully place a nasogastric tube for decompression, insert a urinary catheter, expedite diagnostic evaluation, and obtain immediate surgical consultation. Definitive treatment is usually surgical repair; endoscopic stenting or conservative management may be considered in selected patients with contained perforations. Begin broad-spectrum IV antibiotics targeting oral and gastrointestinal flora.
Medications
Ampicillin/sulbactam 3 g IV q6h; Gentamicin 2 mg/kg loading dose then 1.7 mg/kg q8h or 5–7 mg/kg daily; Imipenem/cilastatin 250–500 mg IV q6h; Dopamine 2–20 μg/kg/min IV as needed.
Disposition
All patients require admission to a surgical ICU. Cervical perforations may be managed with drainage alone, whereas thoracic and abdominal perforations require operative repair. There is no role for ED discharge.
Consultation and Follow-Up
Immediate involvement of thoracic or general surgery is mandatory. Ongoing management and follow-up are dictated by the surgical team.
Key Clinical Insights And Common Errors
Early chest radiographs may appear normal. Left-sided pleural involvement typically indicates distal esophageal rupture, whereas right-sided involvement suggests a proximal tear. A negative initial esophagram does not exclude injury—repeat imaging in decubitus positions if suspicion remains high. Delays in diagnosis and intervention markedly increase mortality; rapid recognition and early surgical consultation are essential.
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