Critical Cases - Boerhaave's Syndrome Emergency!



  • 71 yo male is boarding in the ED after an admission for a RLE DVT
  • On day 2 of his hospital admission, he has several episodes of emesis
  • He begins complaining of chest pain, and vital signs reflect new hypotension, tachycardia and hypoxia


T: 99.9  HR 124  BP 74/42 RR 30 Pox 88% on RA

  • Appearance: Ill appearing, tachypneic, in distress, clutching chest
  • Heart: Tachycardic
  • Lungs: Diminished breath sounds on the left
  • Abdomen: soft, NTND
  • Extremities: cool with intact distal pulses, erythema and edema of RLE known to have DVT


  • ECG: Sinus tachycardia, no ST/T wave abnormalities
  • CXR:



CXR interpretation: L sided pleural effusion



  • Intubtated and started on broad spectrum antibiotics
  • Started on vasopresors for worsening hypotension with MAPs in the 40s 
  • A left sided chest tube was placed which drains ~5 liters of dark brown-black liquid which appears identical to orogastric tube drainage
  • A STAT portable xray after instillation of oral contrast via OG tube into esophagus shows distal esophageal contrast leak confirming suspected diagnosis of esophageal perforation 


Outcome and Teaching Pearls


  • Cardiothoracic surgery evaluated pt but he was determined to not be a surgical candidate
  • GI performed endocscopy demonstrating a large 4cm full thickness perforation of the distal esophagus with freely visible contaminated mediastinum
  • An esophageal stent is inserted
  • Pt continues to decompensate and ultimately dies
  • Esophageal perforation from forceful vomiting (i.e. Boerhaave's syndrome) or instrumentation is a medical and surgical emergency
  • Presents with sudden onset severe, unrelenting, sharp retrosternal chest pain and hemodynamic instability, including hypotension, tachycardia, and tachypnea rapidly leading to shock
  • Hamman's Crunch/Hamman's sign: a sign of pneumomediastinum, a crunching sound on cardiac auscultation
  • Chest Xray often demonstrates pleural effusion (from the leakage of GI content), pneumothoraxes (usually on the left, as in this case), and pneumomediastinum. 
  • A CT scan with water soluble oral contrast (Gastrografin) or an endoscopy will make the diagnosis
  • Treatment: early broad spectrum antibiotics and operative management 
  • Without operative intervention, the mortality is 100%



Soreide J and Vista A. Esophageal perforation: diagnostic work-up and clinical decion-making in the first 24 hours. Scand J Trauma Resusc Emerg Med: 2011; 19:66/