Boerhaave Syndrome

Introduction

Boerhaave syndrome is a rare but life-threatening surgical emergency caused by spontaneous full-thickness rupture of the oesophagus, most commonly following forceful vomiting. The result is contamination of the mediastinum with gastric contents, leading to mediastinitis, sepsis, and multiorgan failure if not recognised and treated promptly.

Peak Incidence

• Typically occurs between 50–70 years of age.
• The distal posterolateral oesophagus is most commonly affected.
• More common in males and in individuals with a history of alcohol misuse or excessive vomiting.

Pathophysiology

• A sudden rise in intraoesophageal pressure, combined with negative intrathoracic pressure (e.g. during vomiting or retching), causes the mucosa and muscular layers to tear, resulting in a transmural rupture.
• The rupture allows gastric contents and bacteria to enter the mediastinum, leading to mediastinitis, pleural contamination, and systemic infection.
• If untreated, this can progress to sepsis, multiorgan failure, and death.

Symptoms

• Severe, sudden-onset chest pain, often radiating to the back, shoulders, or epigastrium.
• Pain may worsen with swallowing or deep breathing.
• History of vomiting or retching prior to symptom onset (classic in 70–80% of cases).
• Associated symptoms may include dyspnoea, dysphagia, or haematemesis.

Signs

• Subcutaneous emphysema: palpable crepitus over the neck or upper chest wall.
• Hamman’s sign: a crunching, rasping sound heard over the precordium, synchronous with the heartbeat (due to mediastinal air).
• Signs of sepsis or shock:
  • Tachycardia
  • Hypotension
  • Tachypnoea
  • Fever

Diagnosis

Clinical suspicion is essential in any patient with acute chest pain following vomiting.

Imaging investigations:

• Chest X-ray:
  • Pneumomediastinum (air in the mediastinum).
  • Left-sided pleural effusion.
  • Subcutaneous emphysema.
• CT thorax with contrast (gold standard):
  • Identifies the site and extent of rupture.
  • Demonstrates mediastinal air, oesophageal wall defect, and fluid collection.
• Contrast oesophagography (if CT inconclusive):
  • Use water-soluble contrast (e.g. Gastrografin) initially to minimise risk of chemical mediastinitis.
  • If negative and suspicion remains high, follow with barium swallow for higher sensitivity.

Complications

• Mediastinitis (life-threatening infection of the mediastinum).
• Sepsis and septic shock.
• Empyema or pleural effusion containing food debris or gastric acid.
• Multiorgan failure.
• Death, if diagnosis is delayed or untreated.

Management

Initial Resuscitation

• ABCDE approach.
• High-flow oxygen and IV fluid resuscitation.
• Nil by mouth and initiate total parenteral nutrition (TPN).
• Broad-spectrum IV antibiotics (e.g. piperacillin–tazobactam) to cover anaerobes and gram-negative organisms.
• Pain control and close monitoring in a high-dependency or intensive care setting.

Conservative Management

• May be considered in small, contained perforations without systemic signs and minimal contamination.
• Includes:
  • IV antibiotics
  • Nil by mouth
  • Serial imaging to monitor resolution

Surgical or Interventional Management

• Early diagnosis (<12 hours):

  • Primary surgical repair of the oesophageal tear is preferred.

• Delayed presentation (>12–24 hours) or if sepsis is established:

  • Debridement, drainage, and possible creation of a controlled oesophagocutaneous fistula using a T-tube.

• Endoscopic stent placement may be considered in selected patients as an alternative to surgery.