A 71 yo male with a history of esophageal varices c/o severe, sharp chest pain and hematemesis.  One week prior he had nine bands applied to esophageal varices during an endoscopic procedure.  He is acutely ill and has subcutaneous emphysema on exam.  A chest radiograph is shown.  What's the diagnosis?  Scroll down for answer.  

Answer:  Boerhaave's Syndrome

• A full thickness esophageal tear caused by a transient surge in intraesophageal pressure as with forceful vomiting (less commonly with seizures, childbirth, or weightlifting)
• High mortality rate, patients can quickly deteriorate to septic shock
• Subcutaneous emphysema (arrow) or mediastinal air may be seen on chest radiograph
• Chest xray is most commonly abnormal and chest CT with water soluable contrast may reveal extravasation of contrast
• Broad spectrum antibiotics, IV fluid resuscitation, and surgical consultation are warranted
• Other causes of esophageal perforation are iatrogenic, foreign body/food impaction, trauma, infection and malignancy
• Surgical repair is indicated for abdominal esophageal perforations and patients with signs of shock or instability
• Endoscopic repair with stenting and biodegradable polymers has been reported

Tintinallyi JE, Stapczynski JS, Ma OJ, YealyDM, Meckler GD, Cline. (2016) Tintinalli’s Emergency Medicine: A Comprehensiv Study Guide, 8e. McGraw Hill.

Dickinson, et al.  Utility of endoscopic therapy in the management of Boerhaave syndrome.  Endoscopy International Open, 2016, 4(11).

Ishikawa, Y., et al. Endoscopic Treatment of Boerhaave Syndrome Using Polyglycolic Acid Sheets and Fibrin Glue: A Report of Two Cases. Journal of Nippon Medical School, 2017, 84(5).