Boerhaave Syndrome

General Considerations

•     Nearly all esophageal perforations are caused by trauma

      • Causes include:

            > Iatrogenic–endoscopy (about 75% of the perforations in adults), dilatation procedures

            > Stab wounds

            > Occasionally, blunt compression of the chest

            > Severe vomiting or straining

• Non-traumatic causes include neoplasm or caustic ingestion

• In infants, the most frequent site of rupture is the cervical esophagus 2° passage of tubes

Boerhaave's Syndrome

      • Usually in men, although neonatal esophageal rupture occurs primarily in girls

      • Associated with the clinical triad of vomiting, chest pain and subcutaneous/mediastinal emphysema

      • In neonates, there is cyanosis and dyspnea associated with a right tension pneumothorax immediately after birth

      • In Boerhaave’s, the inciting cause may be vomiting, straining, childbirth or a blunt blow to the abdomen or thorax

      • Tears are vertically oriented, 1-4 cm in length

      • Almost all (90%) occur along the left posterolateral wall of the distal esophagus

Photo shows extraluminal contrast
arising from left, posterolateral tear of esophagus

Imaging

      • Mediastinal emphysema

      • Left pleural effusion

Photo shows mediastinal emphysema and
extraluminal contrast in pleural space on left

      • Mediastinal widening

      • Subcutaneous emphysema

      • Nacleiro sign-a V-shaped radiolucency seen through the heart representing air in the left lower mediastinum that dissects under the left diaphragmatic pleura

      • In neonatal rupture, pneumomediastinum is uncommon

      • Method of study:

            • First use a water-soluble contrast agent (Gastrografin, oral Hypaque)

            • If no perforation is found, then barium may be used