Synopsis
Recognise oesophageal perforation before shock develops, define the leak rapidly and coordinate resuscitation, contamination control and expert source control.
- Boerhaave syndrome is a spontaneous full-thickness oesophageal rupture produced by a sharp pressure rise, classically after forceful vomiting against a closed upper sphincter.
- Iatrogenic endoscopy, dilation, surgery, foreign bodies, cancer and caustic injury cause more oesophageal perforations overall than spontaneous rupture in many services.
- The classic combination of vomiting, severe chest pain and subcutaneous emphysema is insensitive; tachycardia or an unexplained pleural effusion may appear first.
- Thoracic leakage rapidly contaminates the mediastinum and pleural cavity with saliva, gastric contents and mixed organisms, driving sepsis and organ failure.
- Keep nil by mouth, obtain large-bore IV access, give analgesia and early broad-spectrum IV antibacterials, and involve critical care, radiology and specialist surgeons at presentation.
- Contrast-enhanced CT of the neck, chest and upper abdomen, with carefully selected water-soluble oral contrast, is the practical first-line map of leak and contamination.
- A normal chest radiograph, absence of fever or early normal inflammatory markers does not safely exclude perforation.
- Treatment may use primary surgical repair, resection, drainage, endoscopic clipping, covered stenting or endoluminal vacuum therapy according to site, delay, contamination and expertise.
- Non-operative care is reserved for rigorously selected stable patients with a contained leak, minimal contamination and close expert monitoring, not simply for those presenting late.
- Source control includes drainage of pleural or mediastinal sepsis and a nutrition plan; sealing the luminal defect alone can fail when infected collections remain.
Key red flags
Sudden severe lower chest or epigastric pain follows repeated vomiting and is accompanied by breathlessness, painful swallowing, tachycardia or rapidly developing systemic illness.
Persistent pain, fever, hypoxia, crepitus or haemodynamic change begins after dilation, difficult endoscopy, transoesophageal procedure or upper-GI surgery and exceeds expected discomfort.
Neck pain, dysphagia, odynophagia, voice change, local swelling or palpable gas follows instrumentation or a sharp foreign body and can track into the mediastinum.
Acute dyspnoea, unilateral reduced air entry, pleuritic pain or a new hydropneumothorax may dominate when a thoracic defect decompresses into the pleural cavity.
Fever, confusion, oliguria, rising oxygen need, acidosis and shock develop as contaminated collections spread, sometimes after a deceptively mild initial period.
A small localised contrast leak may occur in a stable patient without diffuse contamination, but apparent containment requires specialist imaging review and serial reassessment.
Investigation priorities
Detect shock, respiratory failure and deterioration while diagnosis proceeds.
Management branches
A compatible trigger is followed by severe pain, respiratory findings or systemic deterioration.
- Keep nil by mouth, assess airway and breathing, give oxygen when indicated, obtain large-bore IV access and begin careful resuscitation, analgesia and continuous monitoring.
- Call the on-call upper-GI or thoracic surgeon, anaesthetist or critical-care team and radiologist immediately, and arrange transfer to a specialist centre if capability is absent.
- Take blood cultures without delaying treatment and start broad-spectrum intravenous antibacterials covering oral and upper-GI organisms under the local perforation or sepsis regimen.
- Obtain urgent contrast-enhanced CT with an agreed oral contrast component and decompress or drain life-threatening pleural tension only through senior specialist direction.
A small well-contained perforation is found in a stable patient without diffuse sepsis or distal obstruction.
- Have the specialist team confirm containment, free drainage back into the lumen, minimal contamination and the ability to deliver immediate rescue intervention.
- Continue nil by mouth, IV antimicrobials, acid suppression where indicated, thrombosis prevention and a jejunal or parenteral nutrition plan agreed by nutrition specialists.