Sections

Presentation

History

The classic clinical presentation of Boerhaave syndrome usually consists of repeated episodes of retching and vomiting, typically in a middle-aged man with recent excessive dietary and alcohol intake.

These repeated episodes of retching and vomiting are followed by a sudden onset of severe chest pain in the lower thorax and the upper abdomen. The pain may radiate to the back or to the left shoulder. Swallowing often aggravates the pain.

Typically, hematemesis is not seen after esophageal rupture, which helps to distinguish it from the more common Mallory-Weiss tear.

Swallowing may precipitate coughing because of the communication between the esophagus and the pleural cavity.

Atypical clinical features sometimes delay obtaining a prompt diagnosis and the adminstration of appropriate intervention. This may result in an increase in morbidity and mortality.

Shortness of breath is a common complaint and is due to pleuritic pain or pleural effusion.

Other conditions to consider include spontaneous intramural esophageal perforation and spontaneous intramural hematoma of the esophagus (esophageal apoplexy).^[8]

Physical Examination

Although the Mackler triad of vomiting, lower thoracic pain, and subcutaneous emphysema is the classic presentation of Boerhaave syndrome, this triad is actually rare, which may then lead to a delay in diagnosis.^[9]

Patients' presentation may vary depending on the following:

The location of the tear
The cause of the injury
The amount of time that has passed from the perforation to the intervention

Patients with cervical esophagus perforation may present with neck or upper chest pain.

Patients with middle or lower esophagus perforation may present with interscapular or epigastric discomfort.

Findings of pleural effusion are common.

If present, subcutaneous emphysema is particularly helpful in confirming the diagnosis. This feature is seen in 28-66% of patients at initial presentation. More typically, subcutaneous emphysema is found later.

Other classic findings include tachypnea and abdominal rigidity.

Tachycardia, diaphoresis, fever, and hypotension are common, particularly as the illness progresses. However, these findings are nonspecific.

Unusual findings may include the following:

Peripheral cyanosis
Hoarseness of the voice due to recurrent laryngeal nerve involvement
Tracheal and mediastinal shift
Cervical vein distention
Proptosis

Pneumomediastinum is a very important finding. It may cause a crackling sound upon chest auscultation, known as the Hamman crunch. The crunch is typically heard coincident with each heartbeat and may be mistaken for a pericardial friction rub. This is present in 20% of patients.

Later stages of the illness may manifest with signs of infection and sepsis. Symptoms may include fever, hemodynamic instability, and progressive obtundation. Establishing a diagnosis in the later stages can be quite difficult, because septic complications begin to dominate the clinical picture. Again, early diagnosis is critical.

Differential Diagnoses

Turner AR, Turner SD. Boerhaave syndrome. StatPearls [Internet]. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Korn O, Onate JC, Lopez R. Anatomy of the Boerhaave syndrome. Surgery. 2007 Feb. 141(2):222-8. [QxMD MEDLINE Link].
de Schipper JP, Pull ter Gunne AF, Oostvogel HJ, van Laarhoven CJ. Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Dig Surg. 2009. 26(1):1-6. [QxMD MEDLINE Link].
Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome. Thorac Cardiovasc Surg. 2010 Dec. 58 (8):476-80. [QxMD MEDLINE Link].
Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004 Apr. 77 (4):1475-83. [QxMD MEDLINE Link].
Kish GF, Katske FA. A case of recurrent Boerhaave's syndrome. W V Med J. 1980 Feb. 76(2):27-30. [QxMD MEDLINE Link].
Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg. 1986 Sep. 42(3):235-9. [QxMD MEDLINE Link].
Restrepo CS, Lemos DF, Ocazionez D, Moncada R, Gimenez CR. Intramural hematoma of the esophagus: a pictorial essay. Emerg Radiol. 2008 Jan. 15(1):13-22. [QxMD MEDLINE Link].
Garas G, Zarogoulidis P, Efthymiou A, et al. Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial. J Thorac Dis. 2014 Dec. 6 (12):1655-8. [QxMD MEDLINE Link].
Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR. Selective nonoperative management of contained intrathoracic esophageal disruptions. Ann Thorac Surg. 1979 May. 27 (5):404-8. [QxMD MEDLINE Link].
Ghassemi KF, Rodriguez HJ, Vesga L, et al. Endoscopic treatment of Boerhaave syndrome using a removable self-expandable plastic stent. J Clin Gastroenterol. 2007 Oct. 41(9):863-4. [QxMD MEDLINE Link].
Zisis C, Guillin A, Heyries L, et al. Stent placement in the management of oesophageal leaks. Eur J Cardiothorac Surg. 2008 Mar. 33(3):451-6. [QxMD MEDLINE Link].
Laukoetter MG, Mennigen R, Neumann PA, et al. Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study. Surg Endosc. 2017 Jun. 31 (6):2687-96. [QxMD MEDLINE Link].
Loske G, Schorsch T. [Endoscopic vacuum therapy for Boerhaave's syndrome] [German]. Chirurg. 2016 Aug. 87 (8):676-82. [QxMD MEDLINE Link].
Adam A, Watkinson AF, Dussek J. Boerhaave syndrome: to treat or not to treat by means of insertion of a metallic stent. J Vasc Interv Radiol. 1995 Sep-Oct. 6(5):741-3; discussion 744-6. [QxMD MEDLINE Link].
Adams BD, Sebastian BM, Carter J. Honoring the Admiral: Boerhaave-van Wassenaer's syndrome. Dis Esophagus. 2006. 19(3):146-51. [QxMD MEDLINE Link].
Bjerke HS. Boerhaave's syndrome and barogenic injuries of the esophagus. Chest Surg Clin N Am. 1994 Nov. 4(4):819-25. [QxMD MEDLINE Link].
Bonheim N, Alavi I. Boerhaave's syndrome: spontaneous rupture of the esophagus. Chic Med Sch Q. 1970. 29(1):31-6. [QxMD MEDLINE Link].
Chiu CL, Gambach RR. Spontaneous perforation of the esophagus (Boerhaave's syndrome). J Iowa Med Soc. 1973 Sep. 63(9):436-8. [QxMD MEDLINE Link].
Clark W, Cook IJ. Spontaneous intramural haematoma of the oesophagus: radiologic recognition. Australas Radiol. 1996 Aug. 40(3):269-72. [QxMD MEDLINE Link].
Craven GG, Whittaker MG. Boerhaave's syndrome as a complication of pre-existent gastrointestinal disease. Ir J Med Sci. 1992 Dec. 161(12):670-4. [QxMD MEDLINE Link].
Crookes PF. RE: Hermann Boerhaave: the man behind the syndrome. Dis Esophagus. 1997 Oct. 10(4):303. [QxMD MEDLINE Link].
Curtis DL, Burbige EJ, Milligan FD. Boerhaave's syndrome: role of esophagoscopy. Gastrointest Endosc. 1976 May. 22(4):208-9. [QxMD MEDLINE Link].
Datta CK, Brannon JV. Spontaneous rupture of esophagus (Boerhaave syndrome): a review of literature and a case presentation. W V Med J. 1979 Jul. 75(7):180-2. [QxMD MEDLINE Link].
Davies AP, Vaughan R. Expanding mesh stent in the emergency treatment of Boerhaave's syndrome. Ann Thorac Surg. 1999 May. 67(5):1482-3. [QxMD MEDLINE Link].
Davis R. The Boerhaave syndrome associated with carcinoma of the oesophagus. S Afr Med J. 1973 Dec 1. 47(47):2269-72. [QxMD MEDLINE Link].
Drury M, Anderson W, Heffner JE. Diagnostic value of pleural fluid cytology in occult Boerhaave's syndrome. Chest. 1992 Sep. 102(3):976-8. [QxMD MEDLINE Link].
Duehring GL. Boerhaave syndrome. Radiol Technol. 2000 Sep-Oct. 72(1):51-5. [QxMD MEDLINE Link].
Dumonceau JM, Deviere J, Cappello M, et al. Endoscopic treatment of Boerhaave's syndrome. Gastrointest Endosc. 1996 Oct. 44(4):477-9. [QxMD MEDLINE Link].
Eubanks PJ, Hu E, Nguyen D, Procaccino F, et al. Case of Boerhaave's syndrome successfully treated with a self-expandable metallic stent. Gastrointest Endosc. 1999 Jun. 49(6):780-3. [QxMD MEDLINE Link].
Hansen CP, Bertelsen S. Boerhaave's syndrome: spontaneous rupture of the oesophagus. Ann Chir Gynaecol. 1988. 77(4):138-41. [QxMD MEDLINE Link].
Henderson JA, Peloquin AJ. Boerhaave revisited: spontaneous esophageal perforation as a diagnostic masquerader. Am J Med. 1989 May. 86(5):559-67. [QxMD MEDLINE Link].
Jagminas L, Silverman RA. Boerhaave's syndrome presenting with abdominal pain and right hydropneumothorax. Am J Emerg Med. 1996 Jan. 14(1):53-6. [QxMD MEDLINE Link].
Janjua KJ. Boerhaave's syndrome. Postgrad Med J. 1997 May. 73(859):265-70. [QxMD MEDLINE Link].
Jenkins IR, Raymond R. Boerhaave's syndrome complicated by a large bronchopleural fistula. Chest. 1994 Mar. 105(3):964-5. [QxMD MEDLINE Link].
John BE, Zua MS. Boerhaave's syndrome--an elusive diagnosis. Tenn Med. 1997 Feb. 90(2):56-8. [QxMD MEDLINE Link].
Kallis P, Belsham PA, Pepper JR. Spontaneous rupture of the oesophagus (Boerhaave's syndrome): conservative versus surgical management. J R Soc Med. 1991 Nov. 84(11):690-1. [QxMD MEDLINE Link].
Klausner JM, Epstein L, Peer G, et al. Perforation of the esophagus (Boerhaave's syndrome) during hemodialysis. Nephron. 1985. 40(3):372-3. [QxMD MEDLINE Link].
Klin B, Berlatzky Y, Uretzky G. Boerhaave's syndrome: case report and review of the literature. Isr J Med Sci. 1989 Feb. 25(2):113-5. [QxMD MEDLINE Link].
Kyriacou DN. A case of Boerhaave's syndrome presenting as diffuse left pulmonary infiltrate. Ann Emerg Med. 1991 Nov. 20(11):1239-42. [QxMD MEDLINE Link].
Lawrence DR, Ohri SK, et al. Primary esophageal repair for Boerhaave's syndrome. Ann Thorac Surg. 1999. 67(3):818-20. [QxMD MEDLINE Link].
Levinsky L, Adler RH. Recurrent diagphragmatic herniation: following gastric onlay reinforcement of esophageal rupture (Boerhaave syndrome). N Y State J Med. 1980 Feb. 80(2):244-8. [QxMD MEDLINE Link].
Levy F, Mysko WK, Kelen GD. Spontaneous esophageal perforation presenting with right-sided pleural effusion. J Emerg Med. 1995 May-Jun. 13(3):321-5. [QxMD MEDLINE Link].
Lin WC, Chen JD, Tiu CM, et al. Boerhaave syndrome with atypical clinical presentations diagnosed by computed tomography. Zhonghua Yi Xue Za Zhi (Taipei). 2002 Jan. 65(1):45-8. [QxMD MEDLINE Link].
Lujan HJ, Lin PH, Boghossian SP, et al. Recurrent spontaneous rupture of the esophagus: an unusual late complication of Boerhaave's syndrome. Surgery. 1997 Sep. 122(3):634-6. [QxMD MEDLINE Link].
Marshall WB. Boerhaave syndrome: a case report. AANA J. 2002 Aug. 70(4):289-92. [QxMD MEDLINE Link].
McCartney J, Dobrow J, Hendrix TR. Boerhaave syndrome. Johns Hopkins Med J. 1979 Jan. 144(1):28-33. [QxMD MEDLINE Link].
Meyer GW, Castell DO. Evaluation and management of diseases of the esophagus. Am J Otolaryngol. 1981 Nov. 2(4):336-44. [QxMD MEDLINE Link].
Michel L. Post-emetic laceration and rupture of the gastroesophageal junction. Acta Chir Belg. 1982 Jan-Feb. 82(1):13-24. [QxMD MEDLINE Link].
Munemura T, Suzuki O, Ootake S, et al. A rare case of spontaneous esophageal rupture (Boerhaave's syndrome) associated with pulmonary rupture. Jpn J Thorac Cardiovasc Surg. 1998 Nov. 46(11):1074-7. [QxMD MEDLINE Link].
Pezzulli FA, Aronson D, Goldberg N. Computed tomography of mediastinal hematoma secondary to unusual esophageal laceration: a Boerhaave variant. J Comput Assist Tomogr. 1989 Jan-Feb. 13(1):129-31. [QxMD MEDLINE Link].
Phillips LG Jr, Cogbill CL, Makkar JC, et al. Barogenic rupture of the esophagus (Boerhaave's syndrome): successful treatment of a late case. Am Surg. 1982 Aug. 48(8):430-4. [QxMD MEDLINE Link].
Rogers LF, Puig AW, Dooley BN, et al. Diagnostic considerations in mediastinal emphysema: a pathophysiologic-roentgenologic approach to Boerhaave's syndrome and spontaneous pneumomediastinum. Am J Roentgenol Radium Ther Nucl Med. 1972 Jul. 115(3):495-511. [QxMD MEDLINE Link].
Rozycki GS. Image of the month. Esophageal perforation (Boerhaave syndrome). Arch Surg. 2001 Mar. 136(3):355-6. [QxMD MEDLINE Link].
Sabanathan S, Eng J, Richardson J. Surgical management of intrathoracic oesophageal rupture. Br J Surg. 1994 Jun. 81(6):863-5. [QxMD MEDLINE Link].
Sakamoto Y, Tanaka N, Furuya T, et al. Surgical management of late esophageal perforation. Thorac Cardiovasc Surg. 1997 Dec. 45(6):269-72. [QxMD MEDLINE Link].
Salim AS. Jejunostomy feeding for the conservative management of spontaneous rupture of the oesophagus. Br J Clin Pract. 1991 Spring. 45(1):37-40. [QxMD MEDLINE Link].
Salo JA, Seppala KM, Pitkaranta PP, et al. Spontaneous rupture and functional state of the esophagus. Surgery. 1992 Nov. 112(5):897-900. [QxMD MEDLINE Link].
Scott HJ, Rosin RD. Thoracoscopic repair of a transmural rupture of the oesophagus (Boerhaave's syndrome). J R Soc Med. 1995 Jul. 88(7):414P-415P. [QxMD MEDLINE Link].
Singh GS, Slovis CM. "Occult" Boerhaave's syndrome. J Emerg Med. 1988 Jan-Feb. 6(1):13-6. [QxMD MEDLINE Link].
Smyth AR, Wastell C. Spontaneous rupture of the oesophagus (Boerhaave's syndrome): delayed diagnosis and successful conservative management. J R Soc Med. 1989 Aug. 82(8):498. [QxMD MEDLINE Link].
Troum S, Lane CE, Dalton ML Jr. Surviving Boerhaave's syndrome without thoracotomy. Chest. 1994 Jul. 106(1):297-9. [QxMD MEDLINE Link].
van Gijn J, Gijselhart JP. [Boerhaave and his syndrome]. Ned Tijdschr Geneeskd. 2013. 157(4):A5460. [QxMD MEDLINE Link].
Van Nooten G, Azagra JS, Alle JL, et al. Spontaneous rupture of the esophagus after coronary artery bypass. Acta Chir Belg. 1987 Nov-Dec. 87(6):367-70. [QxMD MEDLINE Link].
Weil RJ. Candidal mediastinitis after surgical repair of esophageal perforation. South Med J. 1991 Aug. 84(8):1052-3. [QxMD MEDLINE Link].
White RK, Morris DM. Diagnosis and management of esophageal perforations. Am Surg. 1992 Feb. 58(2):112-9. [QxMD MEDLINE Link].
Zawisza MJ, Geisler A. Spontaneous rupture of esophagus (Boerhaave's syndrome): case report and literature review. J Am Osteopath Assoc. 1988 Jun. 88(6):787-90. [QxMD MEDLINE Link].
Loske G, Schorsch T, van Ackeren V, Schulze W, Muller CT. Endoscopic vacuum therapy in Boerhaave's syndrome with open-pore polyurethane foam and a new open-pore film drainage. Endoscopy. 2015. 47 suppl 1 UCTN:E410-1. [QxMD MEDLINE Link].
Barakat MT, Girotra M, Banerjee S. (Re)building the wall: recurrent Boerhaave syndrome managed by over-the-scope clip and covered metallic stent placement. Dig Dis Sci. 2018 May. 63 (5):1139-42. [QxMD MEDLINE Link].

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Author

Praveen K Roy, MD, MSc Clinical Assistant Professor of Medicine, University of New Mexico School of Medicine

Praveen K Roy, MD, MSc is a member of the following medical societies: Alaska State Medical Association, American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Zorisadday Gonzalez, MD Adult Hospitalist, Presbyterian Hospital

Zorisadday Gonzalez, MD is a member of the following medical societies: American College of Physicians, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Mark E Murphy, MD, FACP Assistant Professor of Internal Medicine, Mercer University Medical School; Program Director, Gastroenterology and Hepatology Education, Department of Internal Medicine, Memorial Health University Medical Center

Mark E Murphy, MD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Medical Association of Georgia, Southern Medical Association

Disclosure: Nothing to disclose.

Viswanath Kalapatapu, MD Staff Physician, Department of Internal Medicine, Memorial Health University Medical Center

Viswanath Kalapatapu, MD is a member of the following medical societies: American College of Physicians, American Medical Association

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Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

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Chief Editor

Philip O Katz, MD, FACP, FACG Chairman, Division of Gastroenterology, Albert Einstein Medical Center; Clinical Professor of Medicine, Jefferson Medical College of Thomas Jefferson University

Philip O Katz, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Medtronic<br/>Received income in an amount equal to or greater than $250 from: Torax medical: pfizer consumer, .

Additional Contributors

Manoop S Bhutani, MD Professor, Co-Director, Center for Endoscopic Research, Training and Innovation (CERTAIN), Director, Center for Endoscopic Ultrasound, Department of Medicine, Division of Gastroenterology, University of Texas Medical Branch; Director, Endoscopic Research and Development, The University of Texas MD Anderson Cancer Center

Manoop S Bhutani, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Institute of Ultrasound in Medicine, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Showkat Bashir, MD Assistant Professor, Department of Medicine, Division of Gastroenterology, George Washington University, Washington, DC

Showkat Bashir, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association

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Rahaman Mujibur, MD Academic Hospitalist/Hospitalist, Marshfield Clinic, St Joseph’s Hospital

Rahaman Mujibur, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Wisconsin Medical Society

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Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous coauthor, Prakash Ramanathan, MD, to the development and writing of this article.

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