Snapshot A 19-year-old woman presents to the emergency department with severe retrosternal chest pain. Her symptoms began immediately after vomiting. Medical history is significant for bulimia nervosa. Physical examination is notable for crepitus upon chest wall palpation. A barium swallow study is shown. Introduction Clinical definition spontaneous transmural esophageal rupture secondary to an acute increase in intraesophageal pressure a negative intrathoracic pressure from severe straining or vomiting that contributes to rupture as well Epidemiology associated conditions excessive vomiting and retching e.g., eating disorders and excessive alcohol use Pathogenesis increased intraesophageal pressure and negative intrathoracic pressure usually leads to a perforation in the left posterolateral aspect of the distal thoracic esophagus note that the perforation can also involve the cervical and abdominal esophagus esophageal perforation results in leakage of gastric contents into the mediastinal cavity which leads to chemical mediastinitis mediastinal emphysema mediastinal bacterial infection and necrosis pleural cavity which leads to a pleural effusion Prognosis associated with high morbidity and mortality untreated patients are at risk of sepsis and organ failure this is why early recognition and immediate surgical intervention is required Presentation Symptoms excruciating retrosternal chest pain Physical exam crepitus upon chest wall palpation suggests subcutaneous emphysema Hamman sign mediastinal crackling that is concurrent with each heart beat while the patient is in the left lateral decubitus position Imaging Contrast esophagram indications perform in patients with features concerning for Boerhaave syndrome modality with water soluble contrast (e.g., Gastrografin) Computed tomography (CT) scan indication perform in patients with features concerning for Boerhaave syndrome and who a diagnosis cannot be made on contrast esophagram or the perforation is suspected to be difficult to find Studies Labs complete blood cell count may see a leukocytosis Diagnostic criteria based on clinical presentation and image findings Differential Mallory-Weiss syndrome esophageal rupture is non-transmural and is typically associated with hematemesis Myocardial infarction Pancreatitis Peptic ulcer perforation Aortic aneurysm dissection Spontaneous pneumothorax Treatment Conservative intravenous fluids, antibiotics, and admission to the intensive care unit indication initial management prior to surgical intervention Operative direct repair of esophageal rupture indication for the surgical repair of esophageal perforation in Boerhaave syndrome Complications Sepsis Pneumomediastinum Mediastinitis Empyema Subcutaneous emphysema Mediastinal abscess