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Boerhaave Syndrome

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Boerhaave Syndrome

Boerhaave syndrome is a spontaneous transmural (full-thickness) rupture of the esophagus,
usually following forceful vomiting or retching, resulting in leakage of esophageal contents into the
mediastinum

Also called

Spontaneous Esophageal Rupture

ICD-10

K22.3

Specialty

Gastroenterology

Onset

Acute

Reviewed

July 2026

On This Page

Overview

Boerhaave syndrome is a life-threatening subtype of esophageal perforation caused by a sudden
increase in intrathoracic pressure during forceful vomiting. It most commonly affects the distal third
of the esophagus on the left dorsolateral wall. Prompt diagnosis and treatment are essential to
prevent mediastinitis, sepsis, and death.

Etiology & Risk Factors

• Repeated forceful vomiting or retching
• Recent large intake of alcohol
• Recent large meal
• Prolonged coughing
• Childbirth
• Seizures
• Weightlifting

Pathophysiology

1. Forceful vomiting causes a marked increase in intrathoracic pressure.
2. A full-thickness (transmural) tear develops in the esophageal wall.
3. In over 90% of cases, the rupture occurs in the distal third of the esophagus on the left
dorsolateral wall.
4. Esophageal contents leak into the mediastinum.
5. This can rapidly lead to mediastinitis, sepsis, and multiorgan dysfunction

Clinical Presentation

Classic Mackler triad:
• Vomiting or retching
• Severe retrosternal chest pain (often radiating to the back)
• Subcutaneous or mediastinal emphysema
Other features:
• Dyspnea
• Tachypnea
• Tachycardia
• Dysphagia
• Signs of sepsis
• Delayed presentation may include multiorgan dysfunction

History Taking

  • Ask about:
    • Recent forceful vomiting or retching
    • Heavy alcohol intake
    • Large meal before symptom onset
    • Sudden severe chest pain
    • Pain radiating to the back
    • Dysphagia
    • Dyspnea
    • Recent upper endoscopy
    • Trauma
    • Symptoms of sepsis (fever, chills)

Physical Examination

Assess for:
• Subcutaneous emphysema (neck or suprasternal crepitus)
• Hamman sign (mediastinal crunch synchronous with the heartbeat)
• Tachycardia
• Tachypnea
• Signs of sepsis
• Hemodynamic instability

Investigations

-Initial imaging:
• Chest X-ray
• Upright abdominal X-ray (if indicated)
• Neck X-ray (if cervical perforation is suspected)


-Possible findings:
• Pneumomediastinum
• Pneumothorax
• Pleural effusion
• Subcutaneous emphysema
• Widened mediastinum
• Pneumoperitoneum
• Mediastinal air-fluid levels


-Confirmatory tests:
• Contrast esophagography (gold standard)
• CT chest with CT esophagography (oral contrast when feasible)


-Endoscopy:
• Flexible endoscopy may be used in selected situations but is generally avoided in nonpenetrating
injuries unless there is a specific therapeutic indication.

Diagnosis

  • Diagnosis is usually based on:
    • Clinical suspicion
    • Initial radiographic imaging
    • Confirmation with contrast esophagography and/or CT esophagography

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Management

  • 1. Initial Stabilization

    • Assess Airway, Breathing, and Circulation (ABC)

    • Oxygen therapy

    • Establish large-bore IV access

    • Intravenous fluid resuscitation

    • Hemodynamic monitoring

    • Keep the patient nil by mouth (NPO)

    2. Medical Therapy

    • Broad-spectrum intravenous antibiotics

    • Intravenous proton pump inhibitor (PPI)

    • Adequate analgesia

    • Antiemetics

    • Nutritional support (enteral or parenteral if prolonged NPO)

    3. Definitive Treatment

    Surgical Repair (Preferred)

    Indicated for:

    • Early presentation (<24 hours)

    • Large perforation

    • Sepsis

    • Mediastinitis

    • Hemodynamic instability

    Options:

    • Primary esophageal repair

    • Debridement of contaminated tissue

    • Mediastinal and pleural drainage

    Endoscopic Management

    Selected stable patients with:

    • Small, contained perforations

    • Minimal contamination

    Options:

    • Endoscopic stent placement

    • Endoscopic clips or endoscopic vacuum therapy (selected cases)

    Conservative Management

    Consider only in carefully selected patients with:

    • Small contained leak

    • No sepsis

    • Hemodynamic stability

    • Minimal mediastinal contamination

    Management includes:

    • NPO

    • IV antibiotics

    • IV fluids

    • Close monitoring

    • Nutritional support

    4. Follow-Up

    • Repeat contrast esophagram or CT with oral contrast to confirm healing before resuming oral intake

    • Monitor for infection, mediastinitis, and leak recurrence

    • Gradual return to oral feeding after healing is confirmed

Complications

• Mediastinitis
• Sepsis
• Multiorgan dysfunction
• Pneumomediastinum
• Pneumothorax
• Pleural effusion

Prognosis

  • Prognosis depends on early recognition and prompt treatment.
  • Delayed diagnosis increases the
    risk of mediastinitis, sepsis, multiorgan failure, and mortality.

Key Points / Clinical Pearls

• Boerhaave syndrome is a spontaneous full-thickness esophageal rupture.
• It is most commonly caused by forceful vomiting or retching.
• Heavy alcohol intake and large meals are common risk factors.
• The classic Mackler triad consists of vomiting, severe chest pain, and subcutaneous emphysema.
• Chest X-ray is the initial imaging study.
• Contrast esophagography is the gold-standard confirmatory test.
• CT chest with CT esophagography is useful when the diagnosis is uncertain or the patient is
unstable.
• Surgical repair is the usual treatment.
• Delayed diagnosis greatly increases morbidity and mortality.