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.
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.
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.
A small well-contained perforation is found in a stable patient without diffuse sepsis or distal obstruction.
Key medicines
Broad-spectrum intravenous antibacterial regimenGive immediately using the hospital's current oesophageal perforation and sepsis doses, adjusted for allergy, kidney function, prior colonisation and local resistance; obtain urgent microbiology advice and narrow when cultures and source control allow.
Intravenous proton pump inhibitorUse a licensed intravenous preparation and dose from the current BNF or local upper-GI perforation protocol while enteral dosing is impossible, then reassess the indication and oral conversion after source control.