Sudden, severe retrosternal chest pain or epigastric pain radiating to the back/shoulders. c
Pain is caused by mediastinitis and may not appear until several hours after perforation. c
Odynophagia, dyspnea, and rapid onset of systemic signs (fever, tachycardia, tachypnea, hypotension).
Subcutaneous emphysema: Crepitus palpated in the neck or anterior chest wall.
Hamman sign: Mediastinal “crunching” sound heard synchronous with the heartbeat. c
Caused by air in the mediastinum
Vomiting followed by chest pain (classic Boerhaave presentation).
Diagnosis
Initial: CXR or CT chest/abdomen showing pneumomediastinum, pleural effusion (often left-sided), hydropneumothorax, or subdiaphragmatic air.
Confirmatory/Gold Standard: Esophagography with water-soluble contrast (Gastrografin). c
Water-soluble contrast is preferred initially because it is rapidly absorbed and does not cause chemical mediastinitis if it leaks into the thoracic cavity.
If negative and clinical suspicion remains high, follow with barium esophagography (higher sensitivity but causes chemical mediastinitis if leaked).
CT chest with oral water-soluble contrast is a highly sensitive alternative if esophagography cannot be performed.
Contraindication: Avoid EGD/flexible endoscopy (insufflation of air worsens pneumomediastinum and mediastinal contamination).
Differential Diagnostics
Mallory-Weiss syndrome: Diff by mucosal-only tear at GE junction, presenting with self-limiting hematemesis after vomiting; lacks pneumomediastinum and systemic toxicity. c
Aortic Dissection: Diff by tearing chest pain radiating to back, unequal BPs in bilateral arms, widened mediastinum without pneumomediastinum/crepitus. Confirm with CTA.
Myocardial Infarction: Diff by substernal pressure, diaphoresis, diagnostic ECG changes (ST-elevation/depression) and elevated troponins.
Spontaneous Pneumothorax: Diff by sudden unilateral pleuritic chest pain, decreased breath sounds, hyperresonance to percussion, no mediastinal emphysema.
Management
Immediate Stabilization: NPO, IV access, aggressive IVF resuscitation.
Medical Therapy: IV PPIs, broad-spectrum IV Abx (e.g., Zosyn or Cefepime + Metronidazole) to cover oral flora/anaerobes.
Urgent Surgical Consultation:
Surgical repair/debridement: Indicated for unstable pts, large leaks, significant mediastinal contamination, or presentation < 24 hours.
Esophageal diversion/exclusion: Indicated for severe tissue necrosis or delayed presentation (> 24 hours).
Conservative/Non-operative: Only for stable, asymptomatic pts with well-contained leaks (treated with NPO, IV Abx, and parenteral nutrition).
Complications
Mediastinitis (high mortality rate, leads to septic shock and MODS).