Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
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Mediastinal contamination after oesophageal rupture
Transmural leakage of saliva, gastric contents and bacteria causes rapidly progressive mediastinitis, pleural contamination, shock and multiorgan failure.
Action: Keep nil by mouth, start ABCDE resuscitation and broad intravenous antimicrobial therapy, obtain urgent contrast CT and contact upper-GI surgery, endoscopy, radiology, anaesthesia and critical care for drainage and defect control.
Synopsis
Recognise spontaneous and iatrogenic oesophageal perforation early, resuscitate mediastinal sepsis, define the leak with CT and contrast studies, and obtain immediate expert source-control planning.
Boerhaave syndrome is spontaneous full-thickness rupture after forceful vomiting; iatrogenic injury after endoscopy or dilation is a common alternative mechanism.
The classical triad is insensitive, so use the event and physiological trajectory rather than waiting for vomiting, pain and subcutaneous emphysema together.
Contrast-enhanced CT of neck, chest and upper abdomen with oral contrast when appropriate identifies air, fluid, leak site and pleural or mediastinal contamination.
Key red flags
Severe chest, neck or epigastric pain after vomiting, endoscopy or dilation with tachycardia, dyspnoea, fever or crepitus is perforation until excluded.
Shock, pleural effusion, pneumomediastinum or rapidly increasing oxygen need indicates established contamination and requires immediate source control.
Post-emetic rupture
Abrupt severe chest or epigastric pain after forceful vomiting is the key Boerhaave context, even without palpable crepitus.
Investigation priorities
01
Contrast-enhanced CTFirst step
Map perforation, extraluminal gas, collections and pleural contamination.
Management branches
Emergency source controlOperate on a free contaminated thoracic rupture when feasible
After repeated vomiting, an adult develops shock; CT shows a free distal thoracic leak and a large left pleural collection.
Begin ABCDE resuscitation, keep nil by mouth, obtain blood and pleural cultures only if this causes no treatment delay, and start the hospital’s verified oesophageal-rupture antimicrobial regimen with immediate microbiology input.
Assemble upper-GI surgery, endoscopy, radiology, anaesthesia and critical care and drain pleural contamination promptly; shock and free leakage make simple endoscopic clipping inappropriate even though CT cannot directly certify tissue-edge viability.
Contained cervical injuryUse monitored non-operative care
A small cervical perforation is contained, the patient is stable and there is no distal obstruction.
Key medicines
Dated North Bristol oesophageal-rupture antimicrobial example (current status unconfirmed)North Bristol NHS Trust antimicrobial guideline v7.3 is dated October 2022, was due for review in July 2023 and had no issuing-body confirmation of current validity when checked on 8 September 2026. Its historical adult oesophageal-rupture example is co-trimoxazole 960 mg IV twice daily plus metronidazole 500 mg IV three times daily plus fluconazole 400 mg IV once daily. Although the site table prints five days, the same document directs oesophageal-rupture duration to a medical microbiologist, so duration must follow current receiving-hospital policy and microbiology advice. Co-trimoxazole 960 mg is 10 mL of 16 mg/80 mg per mL concentrate, usually added to 250 mL compatible infusion fluid such as sodium chloride 0.9% and infused over 60–90 minutes. At creatinine clearance 15–30 mL/min use 480 mg every 12 hours; below 15 mL/min this product is not recommended. Infuse metronidazole 500 mg/100 mL at about 5 mL/min. Infuse fluconazole 2 mg/mL at no more than 10 mL/min; for multiple dosing at creatinine clearance 50 mL/min or less in a non-dialysis patient, give the initial dose then 50% of the maintenance dose.Do not use this dated example as a live prescription without current local confirmation and pharmacy/microbiology review of the entire combination. Co-trimoxazole is contraindicated in the first trimester of pregnancy, acute porphyria and previous drug-induced immune thrombocytopenia caused by trimethoprim or a sulfonamide; also exclude relevant hypersensitivity and severe liver impairment. Review renal function, potassium, sodium, blood counts, rash risk and interactions including warfarin, methotrexate, ACE inhibitors, ARBs and potassium-sparing diuretics. The usual 10 mL concentrate-in-250 mL dilution must be checked against fluid status and the exact compatible-fluid table; do not invent a concentrated alternative for fluid restriction. With metronidazole, avoid alcohol, review coumarin anticoagulants and neurological toxicity, and reduce the daily dose to one third in hepatic encephalopathy. With fluconazole, review QT interactions, electrolytes, liver toxicity and sodium/fluid load. Reassess all agents after source control and culture results.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.