Epidemiology & Risk Factors

Iatrogenic trauma (most common, ~75%): Instrumentation during EGD, esophageal dilation, or TEE.
Boerhaave syndrome: Spontaneous barogenic rupture (e.g., severe vomiting/retching, straining, blunt trauma).
Foreign body ingestion (e.g., fish bones, button batteries) or caustic ingestion (acid/alkali).
Pre-existing esophageal pathology (e.g., GERD, Barrett, eosinophilic esophagitis, malignancy).

Clinical Features

Sudden, severe retrosternal chest pain or epigastric pain radiating to the back/shoulders. 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.
Vomiting followed by chest pain (classic Boerhaave presentation).

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).
- 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.
Key Labs: Leukocytosis, pleural fluid analysis (exudative, pH < 6.0, elevated amylase from swallowed saliva).
Contraindication: Avoid EGD/flexible endoscopy (insufflation of air worsens pneumomediastinum and mediastinal contamination).

Mallory-Weiss Tear: Diff by mucosal-only tear at GE junction, presenting with self-limiting hematemesis after vomiting; lacks pneumomediastinum and systemic toxicity.
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.

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).

tags	—
aliases	Boerhaave syndrome