AKT · Gastroenterology/GI bleedinglow yield

Boerhaave syndrome

Spontaneous full-thickness oesophageal rupture from forceful vomiting

Overview

Spontaneous FULL-THICKNESS rupture of the oesophagus from a sudden rise in intra-oesophageal pressure against a closed glottis — classically forceful vomiting/retching (often after alcohol). Leads to mediastinitis and sepsis. The Mackler triad: vomiting → severe chest pain → subcutaneous emphysema. A life-threatening surgical emergency, distinct from the benign mucosal Mallory-Weiss tear.

Recognise

Forceful vomiting/retching THEN severe retrosternal/epigastric chest pain, often with subcutaneous emphysema (crepitus in the neck/chest) — the Mackler triad
Rapidly unwell: dyspnoea, sepsis/shock, signs of mediastinitis; left pleural effusion (often left-sided rupture)
CXR: pneumomediastinum, surgical emphysema, left pleural effusion/hydropneumothorax

Red flags

Sepsis/mediastinitis → emergency resuscitation + surgery (high mortality, time-critical)
Misdiagnosis as MI/pancreatitis/pneumothorax delays life-saving treatment

Differentials & how to tell them apart

Mallory-Weiss tearMUCOSAL tear → haematemesis, self-limiting; Boerhaave is FULL-thickness rupture → mediastinitis, no/little haematemesis

Myocardial infarctionchest pain — ECG/troponin; but the vomiting-then-pain + emphysema sequence points to rupture

Perforated peptic ulcer / pancreatitisabdominal signs, free gas / raised amylase — different free-air pattern

Spontaneous pneumothoraxpleuritic pain/dyspnoea without the vomiting trigger

Investigations

CXR (pneumomediastinum, surgical emphysema, effusion); CT chest with contrast / CONTRAST SWALLOW (water-soluble — confirms the leak). Bloods (sepsis), pleural fluid (high amylase, food particles).

Management

Resuscitate + antibiotics + urgent surgery (repair/stent + drainage)

1Recognise the vomiting → chest pain → subcutaneous emphysema sequence. Resuscitate, nil by mouth, broad-spectrum antibiotics (± antifungal); urgent CT/contrast swallow and surgical referral.Gate: Do NOT mistake it for a Mallory-Weiss tear (mucosal, self-limiting) or an MI — Boerhaave is a full-thickness rupture causing mediastinitis and needs EMERGENCY surgery; delay sharply increases mortality
2Definitive surgery (primary repair if early) or oesophageal stent + drainage; critical care; nutritional support.

Resuscitation + broad-spectrum antibiotics + antifungals + nil by mouth — sepsis/mediastinitis management

Surgical repair / stenting + drainage — definitive — primary repair (early) or stent/drainage; time-critical

Key points

Vomiting → severe chest pain → surgical emphysema (Mackler triad) + pneumomediastinum = Boerhaave (full-thickness rupture) → emergency surgery. The lethal mimic of the benign Mallory-Weiss tear.

Monitor & prognosis

Sepsis; surgical recovery.

High mortality, especially if treatment is delayed.

Source: RCS; BSG