Conditions · Gastroenterology and hepatology

Oesophageal perforation (Boerhaave syndrome) !

A full tear through the wall of the oesophagus, after forceful vomiting (Boerhaave) or a medical procedure. It is a surgical emergency.

Updated 2026-11-01

Structures involved

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Why it happens

What it is

A full-thickness disruption of the oesophageal wall that lets oesophageal and gastric contents leak into the mediastinum or pleural space. Boerhaave syndrome is the spontaneous form caused by a sudden rise in intraoesophageal pressure during vomiting; most perforations today are iatrogenic.

Who gets it

Uncommon but among the most lethal perforations of the gastrointestinal tract. Iatrogenic injury during endoscopy and dilation is the leading cause; Boerhaave syndrome typically affects middle-aged men after heavy eating or drinking.

Causes

Iatrogenic: upper endoscopy, dilation, stent placement, nasogastric or transoesophageal echocardiography probes, thoracic surgery
Spontaneous (Boerhaave): forceful vomiting against a closed upper oesophageal sphincter
Foreign bodies, food impaction and caustic ingestion
Penetrating or blunt trauma
Underlying oesophageal disease: tumours, eosinophilic oesophagitis, strictures

Risk factors

Therapeutic endoscopic procedures, especially dilation
Binge eating and heavy alcohol intake with vomiting
Oesophageal strictures, cancer or eosinophilic oesophagitis
Older age and comorbidity (worse outcome)

Pathophysiology

In Boerhaave syndrome, vomiting raises pressure in the lower oesophagus while the upper sphincter stays closed, and the wall ruptures, usually in the left posterolateral distal oesophagus, just above the diaphragm, where the wall is weakest. Gastric contents and swallowed bacteria spill into the mediastinum, causing chemical and then bacterial mediastinitis, pleural effusion (usually left-sided), sepsis and multiorgan failure.

Classification

By cause: iatrogenic, spontaneous (Boerhaave), traumatic, foreign body
By site: cervical, thoracic or abdominal oesophagus
By time to diagnosis: early (within 24 hours) or late, which strongly affects outcome

Symptoms and signs

Severe retrosternal or upper abdominal pain after vomiting or a procedure
Mackler triad: vomiting, lower chest pain and subcutaneous emphysema
Dyspnoea, tachypnoea and pain on swallowing
Fever, tachycardia and hypotension as mediastinitis and sepsis develop
Neck pain and crepitus in cervical perforation

Diagnosis

Clinical: Suspect it in any patient with chest pain after vomiting or after instrumentation of the oesophagus; examine for crepitus in the neck and chest wall.
Tests: Blood counts, inflammatory markers, lactate, blood cultures. Pleural fluid from a thoracentesis may contain food particles, high amylase and low pH.
Imaging: Chest radiograph may show pneumomediastinum, left pleural effusion or hydropneumothorax. CT of the chest with oral water-soluble contrast is the test of choice to confirm the leak; a contrast oesophagram is an alternative.

Differential diagnosis

Acute myocardial infarction
Aortic dissection
Pulmonary embolism and spontaneous pneumothorax
Acute pancreatitis or perforated peptic ulcer
Mallory-Weiss tear

Goal of treatment

Control the leak and the infection early, drain contaminated spaces, keep the patient nil by mouth with nutritional support, and restore oesophageal continuity.

Treatment

Acute: Resuscitation, nil by mouth, nasogastric decompression under guidance, early broad-spectrum intravenous antibiotics with antifungal cover when indicated, and acid suppression.
Surgical: Surgical repair of the perforation with debridement and drainage of the mediastinum and pleura, especially within 24 hours; resection or diversion when the oesophagus is diseased or the injury is extensive.
Procedure: Endoscopic stent or clip closure plus percutaneous drainage for selected contained or iatrogenic perforations; chest tube for pleural collections.
Conservative: Non-operative management only for small contained leaks in stable patients without sepsis, with close observation.
Follow-up: Intensive care: vital signs and sepsis signs, chest tube output, enteral (jejunal) or parenteral nutrition, and strict nil by mouth until healing is confirmed.

Complications

Mediastinitis and empyema
Sepsis and septic shock
Multiorgan failure
Oesophageal fistula or stricture
Death

Prognosis

One of the most serious GI emergencies. Mortality is high and rises sharply when diagnosis and treatment are delayed beyond 24 hours; early treatment of an iatrogenic perforation carries a better outcome than spontaneous rupture.

Test yourself

Think of the answer, then tap the question to see it.

What is the Mackler triad?

Vomiting, lower chest pain and subcutaneous emphysema, classic for Boerhaave syndrome.

Where does a Boerhaave rupture usually occur?

Left posterolateral wall of the distal thoracic oesophagus, just above the diaphragm.

What is the most common cause of oesophageal perforation today?

Iatrogenic injury during endoscopy, especially dilation.

Which test best confirms the diagnosis?

CT of the chest with oral water-soluble contrast (or a water-soluble contrast oesophagram).

Why does timing matter so much?

Delay beyond 24 hours lets mediastinitis and sepsis develop and greatly increases mortality.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Esophageal perforation: MedlinePlus Medical Encyclopedia (MedlinePlus (U.S. National Library of Medicine), 2024).

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Representative model, for educational purposes only.

Esophagus highlighted on the Durgical 3D model